Goerner, Evelyn own o aeenj urn
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12801
(518) 798-4726
(518) 793-9777
Funeral Dirictor (.-
Name l/ c 1 Z A/ 62n r t-h I e. Case No. pZ _
Date oaf Cremation / /— phi / -
Time Cremation Started _�f oZ0
Time Cremation Completed '? 1 o26 /9 In I
Type of Container C 15//
Remarks _� J /� B O A6F 1 &/Y
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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
PINE PIN 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 Crematorium, Inc. in accordance with and subject to its Rules and
Regulations to cremate the remains of:
Evelyn Goerner Female
(NAME) (SEX)
47730 188Street Flushing,New York 11353
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 19th day of November 19 88
at Adirondack Tricounty Nursing Home, Town of Johnsburg, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Lillian Jannon 47-30 188 Street, Flushing, NY 11353
(NAME) (ADDRESS)
Dear Friend
Relationship to the deceased
Name of funeral home Brewer Funeral Home, Inc. , Lake Luzerne, Ny 12846
IMPORTANT: I represent that t he best of my knowledge, the deceased has or has no pacemaker in his or
her My. (CIRCLE ONE).
I certify that I have t fu power and authorization to arrange for the cremation of the remains and to direct the
disposition of the cremate 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, w ether laimp or de ands are, or are not, wholly groundless, false or fraudulent.
(w G (SIGNATURE OF RELATIV( R LEGAL REP.))
�0 � 114
/ c c�
(<ZDRESS) (ADDRESS)
Signed on this date
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Crematorium, Inc. to d' -ose of the cremated remains as follows:
Mail to
Other arrangements- please specify:
If pulverization of cremated remains is requested, check here: