Hawkins, Wallace 7 7�i77. 7 7
w A
Name Case-Number
Date of Cremation
Time Cremation Sfirted
Time Cremation Completed Olx::�
Type of -container 4:f IrD,50
-temarks
fA
AY7
r
117 L
qw
PV.
rT
Aw
A .2
�•„_ »•;'i•'.' r "e..r:`'�1A yY x .::•�- kx2�".4y ,,,,�� ;i•: :k. .t_ :'Y^' i,... .r�i'>•.- ns.:':Y '"..Y�a-�°" M' -�" %:�f�:frs�. -•�,.
Wk
- Y 2
INFORMATION FOR CREMATORY RECORDS
Nameof Deceased ....................................... .. r4t�__l 14"V........... 1.4......................................................
Late Residence ............................... ..
.......sa�-a.
Place of Birth..............................
........... ...... .
Place of Death .............. .... ... ...
. ...............................................................................
Date of Birth .....I............ .. .....Z
..................................................................................................................
..... ......
Date of Death ................ . .. ......................................................................................................................
Age: Years ...........6.1..../........... Months ................................ Days ..........................
Father's Name ............ .............1PVA,6
Mother's Name
I .........
i. . ........................................................................................
Married........................ Widowe .................. Divorced ................... Single ...................
Name and Address of Near Relative Authorizing permission for Cremation . ..................
4 ..........................
........................1."e- 1& .. ...4-�44L...............S_v.. .............
FuneralIn ............................................ Day ....................... Date ................................. Time .................................
Funeral Home Name ............
Address ................................
CREMATORY RULES AND REGULATIONS
A request for cremation must accompany the remains and be properly signed by the nearest next-of-kin
or other authorized person, in addition to a regular burial permit.
Arrangement for disposition of the cremains must be made on the request form. Any cremains to be
disposed of by the crematory cannot be reclaimed after two years.
Remains will be received on a seven day a week basis between the hours of 8 A.M. and 5 P.M. by
appointment only.
The charge for cremation includes the use of Chapel during working hours is $110.00 which is payable
on arrival.
All remains must be encased in a casket or suitable container.
(NO NON-COMBUSTIBLE MATERIAL WILL BE ALLOWED)
Albany Rural Chapel and Crematorium will not accept any remains which have a Heart Pacemaker of any type
implanted within. If this rule is not adhered to the person authorizing cremation will be responsible for any damage
to our cremation retorts or personal injury which might occur.
CREMATION REQUEST
Permit No. ---------------
To:. l C,
Dated --------
REMATORIU /�---- 19-�i�
ALBANY M Operated by:
Cemetery Avenue
Menands,Albany, New York 12204 Albany Cemetery Association
Telephone 463-7017 Cemetery Avenue
Menands, Albany, New York 12204
The undersigned hereby requests and authorizes, in accordance with and subject to your rules and regulations
as well as those of the State of New York to cremate the remains and casket containing same of ______________.
-- •'��-r � t�.f----------- �� 1�-�_ who died at
on the ----- ------ day of ---�� ''-L4,5-�-------------------------------------- 19_�'
and certifies and represents that he or she has the right to make such authorization and agrees to hold the Crema-
torium, Funeral Home and Funeral Director harmless from liability on account of said authorization.
Witness: ----------------------------------------- (Sigcn=`ature''-o-f a tCe{or-- e-=__'_r_,;;n_1tative)
-
---
----------- Address Q° - - -- -- ------- =`1=-
Funeral t ______ City ___
- State -�F
6:4�Firm-- --- ---`-e.��.f-g.� _ -- --------------------------------------------------•
(What Relation to Deceased or Authority to Sign)
INSTRUCTIONS
Disposition of Cremains
-------------r;� ----------------- -------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
Authorized by -------------------------------------
Received the Cremains of the above named deceased this _____________ day of ------------------------ 19-___
Signed -------------------------------------------