Jones, Robert F. jo tVl,b v ueej2:S t;tij4tV.
riNE V!Ew r[,MFTERY and CRENIATCRIUM
QUAKER !GOAD. QUEENSQU►2Y, NEW YORK 12801
(519) 798 472,3
(5I8) 79:3-4777
Funeral Dirictor
/�� Case No.t � \ b,6WI
Dale of Cremation 6z~ ® L
I'irne Cremation Started
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'i'i.me Crern<ition C��mpleted �io�-� �
Type of Ccmt_air �
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here
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
TOWN OF QUEENSBURY
PINE YIEIi CEMETERY
8
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:
_ J� Dl3C rT S. ToNc 5
(Name) (Sex)
/ 1013P 67 tA Lc ^-). �/ ) 2 V32
(Street) (City) (State) (Zip Code)
who died on 7H F g TN day of 19c/�
at —Cc C/O 5 r-,o9LL5 P EN5 i9'L N• y
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
_ A1an1, TH A P.' I nl t -To n1 r s I AAPL E 57-. C- qt9 n/yi t f Al.V.
(Name) (Address)
Relationship to the deceased W / r L
Name of funeral home 12 �A/C/v/q-/. t RO P) CRT5 1N-. G/QH/J VIL LE Al.
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or has no pacemaker 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 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.
(Witness) (Signature of Relative o� Legal Rep.)
3 /2r t ?-ro (-'J e C 5/: >
Gle/� "�V/ LAN N- 7. C/1A'oViL� C� N• 7
(Address) (Address)
Signed on this date