Clemens, Helen own v lceenj ur .
OWN riNE VIEW CENICTERY and CREMATORIUM
QLlAKFR ROAD, QUEENSQURY, NEW YORK 12801
(518) 798.4 726
(518) 79:3-9777
Funeral Dirictor �i, 49 OL
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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:
(Name) (Sex)
(Street ) (City) (Sta e) (Zip Code)
who died on B��D �G day of 19�L
a t C—A 'Z�_ /�x -
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
All
(Name) (Address)
Relationship to the deceased�s-,-+
Name of Funeral Home
IMPORTANT:
I r esent that to the best of my knowledge, the deceased has or
has no pacemaker 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 cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, Pals o f audulent.
(Wi ne s) (Address)
��
Signature of Relative or Legal Rep. and Address)
Signed on this date :�z19Z
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify :
If pulverization of cremate 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 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
SULLIVAN-MINAHAN-PUTTER, INC.
67 Park--Phone 79?.2067*
GLENS FALLS.NEW YORK 12801
CUSTOMER'S DESIGNATION OF INTENTIONS
FOR DISPOSITION OF CREMATED REMAINS
Full name of deceased /
/� fPl.ue PRINT Nam.1 '
SCHEDULED PLACE OF CREMATION SCHEDULED DATE OF CREMATION
The undersigned persons)making arrangements request the Disposition of Cremains as Indicated below:
( ) Interment or Inurement
PLACE OF INTERMENT OR INTENMENT
( ) Release to:
SPECIFIC NAME
( ) Ship to:
SPECIFIC NAME
STREET ADDRESS CITY L STATE ZIP CODE
( J Other:
I(we)hereby represent th t I am(we ar ►of the s4e of nearest degree of relationship to the deceased and/or are legally authorized or charged with the
responsibility for the final disposition of his/her body,and that the above are fey(our)instructions for the disposition of the cremated remains of the
above named deceased.I(We)state that I(We)understand that the cremalns of the above named deceased may be disposed of in any lawful manner by
the above named funeral home,if said cremalns are unclaimed after 120 days from the date of cremation.
Dated this A, , Ari—y 19
MR. MR.
MRS. MRS
Miss MISS
Add,.as Address
City and State Zip Cod• City and Sur.' Zip Code
Phone Number Phone Number
The undersigned Funeral Director attests to the following:
(1) If the cremated remains of the above named deceased are u/�claimed after 120 days from the date of cremation,said cremalns will be disposed of
in the following manner
(2) A copy of the foregoing Designation of Intentions was given this day of 19
to the person(s)who made arrangements for cremation.
Signtur of Funeral Director Making Arrangments Punted .d Name of Funeral Director
The funeral firm's copy of this Designation of Intentions will hereafter be completed to show the following:
Actual Data of Cremation Nam.of Crematory
Add,.to
C,ty and St... Zip Cod.
Oats of Disposition of cremams Location of Disposition of Cr•mama
Manner of Disposition of Cremains:
Dated this day of _ 19
Signatur.of Person Makino Disposition of Crarnuna Pnn 1.d or T...d N.—.nl P.,.....M.s:nn n:.n i.—nl r•..n..:n.