Knowles, Richard K. vcurL v �cee�2s r��'t�
f'If lE VIEW CENiCTERY irld CREMATORIUM
QUAKER ROAD, Qa18)79U RY. NEW YORK 12801
4726
(5I8) 193-9777 _
Funeral Dirictor t1.vuA � �✓�
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DISP08ffION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
Will call for
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.
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.
R. 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 155.00
Children (age 13 months to 12 years) $90.60
Infants (stillborn to 12 months) $50.00
TOWN OF RUEENSBURY r /
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
i
CREMATE
The undersigned requests and authorize Pine V T
View
ematori
P e
um i
subject to its Rules and Regulations to cremate the remains of: ' n accordance with and
N Richard Kenneth Knowles Sex Male
ame
-
Benson Heights Benson, Vermont 05743
Street
City State Zip Code
who died on
24 day of June 1991
at Rt. 22 -k, West Haven, Vermont
MaceyAddress
Name and address of nearest living relative or name of person authorizing cremation:
Barbara Edwards Knowles
Name Address
Relationship to the deceased Wife
Name of the funeral home Durfee 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 I have the full power and authorization to arrange for the cremation of th
remains and to direct the disposition of the cremated remains, that an e
y 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
4as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent
Wjies7s --Z-
119 �14ain St. Signature o Relative or, Legal Rep.
V ont 0 743 27 Cottage Street
Address Rutland Vermont 05701
Address
Signed on this date June 25, 1991