Welyczko, Mary H. own o
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12801
(518) 798-4726
(518) 793-9777
0
Funeral Dirictor x
Name /ffs'/� /`r
, ® Case No. 20 oZ a
Date of Cremation - �
Time Cremation Started
Time Cremation Completed
Type of Container S"-L! Z? / 5 7r/' 0 1515,C el" 7�� /�Y
RemarksAnir,� /� /j/iC /� 7,��v``- 1,42 r
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I,the undersigned,the next of kin of .. .. . Mary'. H. W e lyC z ko. ... . .. . . . .. ... . . . .. . . . . . .. . . ... . .. . . . . . . .. . . .
deceased,do hereby certify that I have full power and authority to arrange for the cremation of the remains of said deceased and to
direct the disposition of cremated remains, that any personal possessions have either been removed or may be destroyed and
hereby agree to protect,defend and save harmless the Troy Cemetery Association and/or the Gardner Earl Memorial Chapel and
Crematorium from any and all claims and demands for loss or damages which may be made against them or either of them by
reason of,or connected with,the cremation of said remains and/or the disposition of said remains directed by me,whether such
claims or demands are, or are not wholly groundless, false or fraudulent.
It is requested that the following disposition be made of the cremains: (Check One)
( x )Ship to* M. R . Clark, Tnc . , 27 Sarana.n AvP . + Lake Placid , N. Y. 1294.6
The undersigned hereby authorizes the Crematory to deliver the cremains Via REGISTERED U.S. MAIL and agrees to
assume all liability for any damages that may arise from any cause growing out of said delivery and to indemnify and hold
harmless the Gardner Earl Memorial Chapel and Crematorium and/or the Troy Cemetery Association from any and all
claims related to said shipment. The undersigned also agrees to pay the charge for such delivery.
( ) To be called for
( ) Inter in "Oakwood" Lot No. Section Owned by
( ) Place in "URN GARDEN" Location No. Inscription
( )Place in Crematory Niche No. for month(s) Year(s) Perpetuity
( ) Dispose of th remains J.
WITNESS: . .. .. . . .. . . . . . . .. .. .. . Signed: . . . . . . . . . .. . ..
Address: .... .27 .Saranac Ave .. . .. .. . . . ... .. . . . Add . R: .:2:.. . . .t . In... . .oad. .. . . . . . .. . . ..
City:.Lake Placid, State.N�Y.� . 12g�6 Cit�:allston Lake . .State. N.Y.. ..zip12019
. .. .. .. . ... .. . . .. . . . .. .. . . . .. .. . ... . . . .. . . . .. . . . . .. . . .. . .. . . . . .. .. . . .. . . . . . . . . . . . . . .. .. . . . . . . . .. . . . .. .. .. . . .
Cremains received by Date
Address:
Prices Effective,March 1988
CREMATION,ADMINISTRATION COSTS AND RECORDING FEE adult$130.00
Children (Age 13 months to 12 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00
Infants (Stillborn to 12 months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00
Additional Services
Temporary Cremains Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carton & Pacldng Fee for Shipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Included above
Registered Priority Mail with return receipt . . . . . . . . . . . . . . . . . . . . .
CremationCase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00
Storage of cremated remains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . per month 2.00
Perpetual Memorial Niches for Cremated Remains. . . . . . . . . . . . . . . . . . . . . . . . 400.00
Receiving Room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850.00
UrnGarden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975.00
TERMS: All charges must be paid upon placing of order or at the time of Cremation.
BURIAL PERMIT AND THIS AUTHORIZATION MUST ACCOMPANY THE REMAINS AS
NO CREMATION WILL TAKE PLACE UNTIL THESE RULES ARE COMPLIED WITH.
The Gardner Earl Memorial Chapel and Crematorium
operated by
TROY CEMETERY ASSOCIATION
The,
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PHONE 272-7520 CREMATORY—OAKWOOD AVE. TROY, N. Y. 12180
AREA CODE 518 R. 101ST ST. AND 7TH AVE.
/All
No....................................................... 1988 Date..0 c t.,_..2�.x...1..9..8 8.....................................
Name of Deceased .............Mary H.....We.lyezko-.........................._ ......Sex..Female
...............................
Residence U.i-hlein..Mer.cy.-...C.enter.......L�}��...Pla.�i.d,....1`I., .�'.........................._..............................................
City or Town State
Single................................. Married................................. Widow.....XX.................... Widower.............................. Divorced......................
Age...............................75............ Years....................-.................... Months.......................................... Days
Place of Birth .......Liverpl,.... n .................................................................Date of Death....Oet ... 3, 1.9.88
... ••...
Place of Death .......... ihlein -Mercy,Center. Lake Placid, N. Y .
.....................................•---...........................I........
Street, City and State
Name and full address of nearest living relative or name of person Authorizing Cremation
.Mr-.--Anton..•Welycko•--...•-.RD 2 .Esat_Line Road, Ballston Lake, NY 12019 _ _
Name Street, City and State
Relationshipto Deceased.........Son..................................................................................•------...............................................--•-•-•--............._........._........
Medical Attendant ....H...D...WIlsan-,...MD..........II_ihlein...Mer.cy....Lentar.,.....Lake...P.1a c1d.,...-HY........................
Name Street, City and State
Cause of Death ....................HYpertension dlt congestive heart failure
...............................................................................................
M. B . Clark, Inc . , 27 Saranac Ave . , Lake Placid, NY
Name of Funeral Director .............. . •-•-----............ -...._..........--.................
Street, City and State
Cremationon..........................................................................the........................................Time of arrival ..........._..............................................14
The Gardner Earl Memorial Chapel and Crematorium and/or the Troy Cemetery Association is not responsible for errors
from phone orders. Remains will not be accepted for Cremation unless delivered in a combustible casket.*
(*Corrugated cremation cases must have bottom board capable of supporting 350 pounds)
The association reserves the right to refuse cremation when the remains are in a casket made of fiber glass, plastic, metal or
other incombustible material; OR any incombustible material or substances placed within the casket that would be inj:trious or
damaging to the cremation chamber or the operator thereof.The funeral director in charge of the reinains gill be held responsible
for any damages caused by disregarding the above restrictions.
Hours are from 9:00 a.m. to 4:30 p.m. Monday through Friday, Saturdays until 12. No cremations will be performed on
Sunday or Holidays, however remains may be received on these days by special arrangement without additional charge.
SERVICES AVAILABLE IN GARDNER EARL MEMORIAL CHAPEL BY APPOINTMENT AND WITHOUT
CHARGE
NOTICE
"Some heart pacemakers can be dangerous when placed in a cremation chamber. If the pacemaker is not removed,the
family shall be responsible for any damage resulting and the crematory will not be responsible or accept any liability
under those circumstances.