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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its
Rules and Regulations to cremate the remains of:
Terri K. Roark Female
(Name) (Sex)
Route 1 Box 182B Mount Pleasant , Texas 75445
(Street) (City) (State) (Zip Code)
who died on 29th day of March 1988
at Saratoga. Hospital 215 Church St. Saratoga Springs,NY 12866
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mr. Dick Justiss Route 1 Box 182B Mount Plesant, Texas 75445
(Name) (Address)
Relationship to the deceased Father
Name of funeral home William J. Burke & Sons
IMPORTANT:
I represent that to the best of my knowledge,the deceased #Has--er has no pacemaker in *is-or her body.
(CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium, from any and
all claims and demands for loss or damages which may be made against them by reason of, or connected
with the cremation of said remains as directed, whether such claims or demands are, or are not, wholly
groundless, false or fraudulent.
,,�� _ Mr. Dick Justiss
(SEE TELEGRAM SENT TO CREMATORIUM)
(Witness) (Signature of Relative or Legal Rep.)
Route 1 Box 182B
William J. Burke & Sons Mount Plesant, Texas 75445
Sara�oga�p ngs,New York 12866 (Address)
(518) 584.6373
Signed on this date September 9, 1988
DISPOSITION OF CREMATED REMAINS '
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to Bates-Cooper-Weems Funeral Home
1123 North Jefferson, Mount Pleasant, Texas 75445
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here X
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday No
Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance
of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of
Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized person
stating that they do have the power and authority to arrange for the cremation of the remains and to
direct the disposition of the cremated remains, that any personal possessions have either been removed
or may be destroyed and agree to protect, defend and save harmless Pine View Crematorium from any and
all claims and demands for loss of damages which may be made against them by reason of, or connected
with the cremation of said remains and/or disposition of said remains as directed, whether such claims
or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container, Caskets and containers
must be of combustible material.
5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form
before the remains will be accepted.
6. Unless other arrangements are made, the cremated remains will be mailed via Registered U.S. Mail
within three days of cremation to the funeral home handling the service.
Cremation, Administration Costs and Recording Fee:
Adult $125.00
Children(age 13 months to 12 years) 80.00
Infants(stillborn to 12 months) 45.00
Shipping container, carton and packing fee for shipping and registered priority mail with return receipt
included in the above prices.
ADDITIONAL SERVICE
Storage of cremated remains-per month $ 2.00
western unicin Telegram
MESSAGE\ -aQc73�p9 ORIGINATING JAW FILING TIME
NUMBER / 3 OFFICE >
ADDRESS: C�1\J
CITY - STATE & ZIP CODE: Gx,� 1" ) o
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a SIGNED:
3
MAILURAM SERVICE CENIEM
MIDDLETOWNt VA. 22645
09AM
1-01399BA253 09/09/88 ICS IPMMOZC MTN ABLB
00582 TDMT MOORESTOWN NJ 15 09-09 0353P EDT
ON
PINEVIEW CREMATORIAL
QUAKER RD
QUEENSBURY NY 12801 04
4RESEND 1-0033691253)
1 HEREBY GIVE PERMISSION TO WILLIAM J BURKE AND SON FUNERAL HOME
TO CREMATE MY DAUGHTER TERI KAYE ROARK AT THE PINEVIEW 0%
CREMATORY IN THE TOWN OF QUEENSBURY
BLANCHE JUSTISS
DGXA
1453 EST ort
MOMCOMP MGM 0%
Lo Tt) REPLY RY MAILGRAM MESSAGE. SEE REVERSE SIDE FOR WESTERN UNION'S TOLL- FREE PHONE NUMBERS