Emerson, James W. jot U LLee�2s �GN(
riPJE VIEW CENICTERY and CREMATORIUM
QUAKER ROAD, QUEEN
18)798 RY. NEW YORK 12801
4726
(518) 79:3-9777
Funeral Dirictor
v Case No.
LmLe or Cremation
nr Cremation Started l�
'i'i.me Cremation Completed
,1Y1v or Containerd M i
41 ,
D G o0
DISP08I`['ION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the CremAtedppgins TJRg0Y,a'ke, NY, 12 84 7-9 7 0
Mail to Mr s, James Emerson , HCO 1 , Box 31, Deer-Lan
. ,
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here
r
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
(toad, 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
Nine 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.
R. Unless other arrangements are made, the cremated remains will be mailed via Registered
U.S. Mail within three days of cremation to�he funeral home handling the service. There
will be a $10.00 charge for this service.
n
6'
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
� N
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
do
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:
James Waldo Emeeson Male
Name Sex
HCO1 Box 31 Deerland Rd. , Long Lake, NY, 12847-9704
Street City State Zip Code
who died on seventeenth ( 17 ) day of March 1991
at Glens Falls Hospital Glens Falls , NY, 12801
Place Address --
Name and address of nearest living relative or name of person authorizing cremation:
Joanne G. Bmerson HCO1 , Box 31, Deerland Rd. , Long lake, NY, , 12847
Name (Address) '
Relationship to the deceased Wife
Name of the funeral home Sullivan Minahan & Potter, Inc
- Funeral Home.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker 'n 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.
AW'si t�n s Sigt -natu:o Relat ve or Legal Rep.
G 7&4 Deerland Rd. , Long Lake, NY
(Address y� Address
Signed on this date