Burt, Kenneth C. 50tun O ueeni (iGr
rIPlE VIEW CEMCTERY and CREMATORIUM
QIIAKFR ROAD, QUEENSQURY, NEW YORK 12801
(518) 798 4 72G
(5I8) 793-9777
Funeral Dirictor C i2/ Se/Ill
I1•�uiA �� r ll ,�/Y���/7 !J/1 Case No. -*ag3
UaLe of Cremation
1'inM Cremation Started ,��
i
'Time Crewition Completed
'Iyjx� of Container el "Poe M2 IVl
Alt cl �c e) a
DISPOW11ON OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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 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 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
line View Crematorium from any and all claims and demands for loss of damages which may
he made against them by reason•bf, or connected with the cremation of said remains anti/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. AH remains crust be en-cws£d in a casks, or suitable aiteriwite container. Casket's 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 iCibs.ao
Children (age 13 months to 12 years) $00.00
Infants (stillborn to 12 months) $50.00 " '
TOWN OF QUEENSBURY .
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium fr-or if no answer Cemetery 793-9777
AUTIIORIZA71ON 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:
Name Sex
(N Ili 7'eh#I-t- !Ua.)16Kk
Street Cit
Y State Zip Code
who died on %SfA-
day of
at /�f i�0�c L C2n T,�/� a ' IleX.I-T
Place V7`
Address — —
Name and address of nearest living relative or name of person authorizing cremation:
isi� ��a �26 '1 i¢rv�s li�ZC C S R O. .E�t/ Se
Name 2-1963
Address
Relationship to the deceased D,4r,L G 71 P,
Name of the funeral home ,rLc.Sahl �ur%-ejI ,rt
IMPORTANT:
1 represent that to the best cif 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 cremo
remains and to direct the disposition of the cremated remains, that an at in of the
l Poss
have either been removed or may be destroyed, and agree to protect, defend and sa eessions 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.
�i4Y �• �J i �Aso✓ _
Witness
�j Signa ure of Relative or Legal Rep.
/wWiC.[ �r9i..t St-- �h�w— fu
Address 12 / aalo 7 /GI '" ii�/�4 5d,
Address
Signed on this date