Dickinson, Edythe M. UCUrt v GLee�2S �Nl,
riNE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD. QUEE 79U RY. NEW YORK 12801
(5I8) 793-9777
Funeral Dirictor
Case No. ?"l
Vale of Cremation
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'1'inM Cremation Started
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,rime Creakition Completed
ICI of Ccmtainer a Af ,� d
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ne cremated remains as follows:
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'remains is requested, check here A
POLICIES, RULES AND REGULATIONS
will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday.
Jays, arrangements can be made for Saturday. Prearrangements by telephone
r: remains is necessary.
/'rematorium is located on the grounds of the Pine View Cemetery, Quaker
it Queensbury.
brization for cremation properly signed by the nearest next to kin or other authorized
�Ag that they do have the power and authority to arrange for the cremation of
!ns and to direct the disposition of the cremated remains, that any personal possessions
er been removed or may be destroyed and agree to protect, defend and save harmless
1.,9 Crematorium from any and all claims and demands for loss of damages which may
e against them by reason of, or connected with the cremation of said remains and/or
'ion of said remains as directed, whether such claims or demands are, or are not wholly
less, false or fraudulent. This authorization in addition to a regular burial permit must
1pany the remains.
11 remains must be encased in a casket or suitable alternate container. Caskets and
Mainers must be of combustible material. No styrafoam or plastic containers will be accepted.
'I'lie question relative to cardiac pacemakers must be answered on the authorization to
Iremate form before the remains will be accepted..fi. 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. There
will be a $10.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
Adult $140.00
Children (age 13 months to 12 years) $90.00
Infants (stillborn to 12 months) $50.00
ADDITIONAL SERVICE
Storage of cremated remains - per month $2.00
,��..a. yr
PING VIEW
do
CREMATORIU
Quaker Road, Queensbury, New
Phone (518) Crematorium 798-4726 or if no answ
AUTIIORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, i
subject to its Rules and Regulations to cremate the remains of:
Edythe M. Dickinson Female
Name Sex
25 LaRose Garden Glens Falls, new York
Street City State Zip Code
who died on 111st day of Feb. 19 91
at Glens falls Hospital
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
Howard I. Dickinson 28 Van Buren St. South Glens Falls, New York 12803
Name Address
Relationship to the deceased Mother
Name of the funeral home Sullivan Minahan and Potter Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or her body. (CIRCLE ONE)
1 certify that 1 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 — 4ft=�--Io4—
elat ve or Legal Rep.
67 Park St. Glens Falls 28 Vanburen St. South Glens Falls
Address
Address
Signed on this date . 2-2-91