Perry, Margaret own U
rIPJE VIEW C[NICTERY,vut CREMATORIUM
QUAKER ROAD, QU1E,798UI?Y. NEW YORK 12801
8
(518) 79=1-9777
Funeral Dirictor
Case No.
UaLe of Cremation
Tinw! Cremation Started
'Time Creakition Completed
1}•l,e of Container
PIN
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` DISPOSITION OF CRENATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
deliver to: Carleton Funeral Home Inc . , 68 Main St . , Hudson FalLs , . NY
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.
premation, 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 cnnrain(�r, radon an(i• pirking f^e r,)i r.hij:pii,q and registered priority mail with return receipt
incluri—I in rrices.
ADDITIONAL SERVICE
Storage of cremated remains-per month $ 2.00
TOWN OF QUEENSBURY ,
PINE VIEW CEMETERY
b �
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUT110RIZATION 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:
_ Margaret Perry Female
(Name) `»' (Sex)
5 Fourth Avenue , Hudson Falls , NY 1 83q
(Street) (City) (State) (Zip Code)
who died on 12th day of October 19 90
at Glens Falls Hospital , Glens Falls New York -
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
_ Mrs . Dorothy Taylor , 5 Fourth Ave . , Hudson Falls . NY
(Name) (Address)
Relationship to the deceased dauchter
Name of funeral home Carleton Funeral Home Inc .
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
ground] false or fraudulent.
(Witness) (Signature of Rely ive or Lega ep.)
68 Main St . 5 Fourth Ave .
(Address) (Address)
Hudson Falls , NY Hudson Falls , NY
Signed on this dite &C 1 l _��