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Norton, Ada F. own o aeen.4. ar PINE VIEW CEMETERY and CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12801 (518) 798-4726 (518) 793-9777 G Funeral Dirictor Name S, /J /�' /v Q Te A' Case No. Date of Cremation I / ` ` Time Cremation Started �� j 14 Time Cremation Completed �� 0-w /p/ In J Type of Container Remarks X //Y /X�/1 CJ /Y v /,r-7/47 / / c;? >' �Iap-, /Y7� ®� � 've0/Y POLICIES, RULES AND REGULATIONS - 1. The crematorium will be open for cremations 365 days a year, 24 hours a day. Prearrangements by telephone for acceptance of remains is necessary. 2. Pine Crematorium, Inc. is located on the grounds of the Regan & Denny Funeral Service, Inc., Quaker Rd., Town of Queensbury - adjacent to Pine View Cemetery,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 Crematorium, Inc., 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. PRICES EFFECTIVE MAY 1, 1986 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 y= - t , PINE PINE CREMATORIUM, INC. Quaker Road, Glens Falls, NY 12801 CREMATORIUM,INC. Phone (518) 798-4726 or if no answer,792-1114 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine Crem torium, Inc. in accordance with and subject to its Rules and Regulations to cremate the remains of: • � ', (PIA f.1 E) (SEX) BB (STREET) (CITY) (STATE) (ZIP CODE) who died on ��/�S r day of 19 at 7 (PLACE) (ADDRESS) Name and address of n arest living relative or name of person authorizing cremation: 11� Into-�- - 1,A) )-,3J1- -Z1 (NAME) JADDRESS) G 1 IA/A k"'d Relationship to the deceased ` L li�` �� ati Y) Name of funeral home S G Sr S , 1 IMPORTANT: I represent that to the best of my knowledge, the deceased has or has acemaker in his 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 Crematorium, Inc. 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. 02&111 (WITNESS) (SIGNATURE OF RELATIVE OR LEGAL REP.) j�DD � J� �(� j (ADDRESS) AlY Signed on this date V. DISPOSITION OF CREMATED REMAINS I hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows: Mail to , �� T�1•c.�r�lQ C, 114 kc- r-F4 r t,r" Other arrangements - please specify: If pulverization of cremated remains is requested, check here: