Ryder, Shirley N. jotvl,t 01Q
ritlE VIEW CENICTERY and CREMATORIUM
QUAKER ROAD. QUEE)798URY. NEW YORK 12801
-4726
(5I8) 793-9777
Funeral Dirictor � 0� �'
Case No. oho
Dale Of Cremation
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DISP081CION OF CREMATED REMAINS
I hereby direct Pi a View Crematorium to dispose of the cremated remains as follows:
Mail to 40
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
(toad, Town of Queensbury.
i. An authorization for cremation properly signed by the nearest next to kin or other authorized
son stating that they do have the power and authority to arrange for the cremation of
remains and to direct the disposition of the cremated remains, that any personal possessions
either been removed or may be destroyed and agree to protect, defend and save harmless
°ew Crematorium from any and all claims and demands for loss of damages which may
against them by reason of, or connected with the cremation of said remains and/or
of said remains as directed, whether such claims or demands are, or are not wholly
false or fraudulent. This authorization in addition to a regular burial permit must
he remains.
must be encased in a casket or suitable alternate container. Caskets and
,e of combustible material. No styrafoam or plastic containers will be accepted.
tive to cardiac pacemakers must be answered on the authorization to
the remains will be accepted.
'tents are made, the cremated remains will be mailed via Registered
a of cremation to the funeral home handling the service. There
`his service.
and Recording Fee:
a�
$140.00
12 years) $90.00
ths) $50.00
-)DITIONAL SERVICE
— per month $2.00
TOWN OF QUEENSBURY �
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
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:
ShirleyN. R der Female
Name Sex
8203 Regency Park eensbury NY 12804
Street City State Zip Code
who died on 1 day of December 19_go_
at Glens Falls Hospital
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
George Ryder 8203 Regency Park, Queensbury, NY 12804
Name Address
Relationship to the deceased Husband
Name of the funeral home Sullivan, Minahan & Potter, Inc.
IMPORTANT:I represent that to the best of my knowledge, the deceased has or ha no pa_
cema-k-e--r 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 harmle
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 fra
9
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Witne s :gna re of Re t r galRep.)
67 PArk Street, Glens Falls, NY 8203 Regency Park, Queensbury, NY 12804
Address 12801 Address
Signed on this date