Eddy, Dorothy jotlul,b v �cee�2:s �cN(
riNE VIEW CENlCTERY and CREMATORIUM
QUAKER ROAD. Q EE 7O Y. NEW YORK 12801
98-4726
(518) 79:3-9777 �p
Funeral Dirictor 41,91,ko/1 —
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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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 Ilolidays 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 to 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
he 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. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains-will be accepted.
F. 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
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
'rhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
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N a me Sex
0 A, 10 4-MN k
Stree ity State Zip Code
who died on
day of 19
at
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
Q-0-54 ftA
a me Address '
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Relationship to the deceased
Name of the funeral home�ffia-LLL�,
IMPORTANT:
1 r=esent that to the best of my knowledge, the deceased has or ha acemaker in his
orl&body. (CIRCLE ONE) .no
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
a e made aim them by reason of, or connected with the cremation of said remains
as dir cted h er ch claiit ms or demands are, or are not, wholly groundless, false or fraudulent.
Witness
ig ture o Relat ve or 1 Rep.
Addr ss Address
Signed on this date
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