Roberts, Mary R. jotun v ueen2o ur .
rmE v1EW CENICTERY a"(I CREMATORIUM
QUAKER (QUAD, QUEE 7[3 I Y, NEW YORK 12801
i
(518) 793-9777
Funeral Dirictor �
7 Case No.
UnLe o•E Cremation
'1'inw, Cremation Started / ®
Time Crenkition Completed
of Ccmtainer
1?cnw'►r.ks
i
30 /� il✓� r
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify : Burke F.H. will pick up.
If pulverization of cremate remains is requested, check here XXX
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 Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
next of 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 be 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.
6. 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. 00 Infants (stillborn
to 12 months) $50. 00
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Peary R. Roberts Female
(Name) (Sex)
331 1111zowland St. , Ballstnn Spa, T�Y 12020
(Street ) (City) (State) (Zip Code)
who died on 16 day of August 19 91
at Saratoga Hospital, Saratoga Springs, TTY 12866
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Terry Parish 17 Spa Circle , Saratog. Springs, T;Y 12866
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home 'illiam J. Durke ^ons Funeral Home
IMPORTANT:
I re resent that to the best of my knowledge, the deceased has or
efias no acemaker 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 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 cr tionp��of said remains as
s3
directed, whether such claims or demmj q1 JarEejrkp-& 5aan& not wholly
groundless, false or fraudulent. North Broadway
Saratoga SPs,New 518)584.5373ork 12866
(Witness) (Address)
(Signa q
re of Relative or Legal Rep. and Address)
August 17, 10/91
Signed on this date :