Wikoff, Climena vcvi-t v �cee�2:f ���
PINE VIEW CEMCTERY and CREMATORIUM
QL►AKF.R ROAD, QUEENSDUIZY, NEW YORK 12801
(518) 798.4 726
(518) 793-9777
1
Funeral Dirictor /13 r19 M //ti/G
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to M. B . Clark Inc .
27 Saranac Ave „ Lake Placid, N. Y. 12946
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
I. 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
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 $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 $2.00
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
l - "T8'-'
AUTHO I A N TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Qlimpng K. Wikoff Female
Name Sex
Old Military Road Lake Placid N . Y. 12946
Street City State Zip Code
who died on 19th day of February 1992
at Uihlein Mercy Center Lake Placid, N. Y .
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
---Robert Wikoff Old Militar Road, Lake Placid, N. Y. 1294.6
Name Address
Relationship to the deceased Son
Name of the funeral home M. B . Clark, Inc . , 27 Saranac Ave . , Lake Placid, NY
IMPORTANT:
12946
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or her body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the
remains and to direct the disposition of the cremated remains, that any personal possessions
have either been removed or may be destroyed, and agree to protect, defend and save harmless
Pine View Crematorium, from any and all claims and demands for loss or damages which
may be made against them by reason of, or connected with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
W tness Signature of Relative or Legal Rep.)
g �
2 Saranac Ave . Lake Placid d Militar Road
Address (Address) Plnnirl-
Signed on this date_ Feb . 20 1992
I,the undersigned,the next of kin of .. ..Cl imena.M.. .illi�.$o.#'f... .. . .. . . . ... .
deceased,do hereby certify that I have full power and authority to arrange for the cremation of the remains of said deceased and to
direct the disposition of cremated remains, that any personal possessions have either been removed or may be destroyed and
hereby agree to protect,defend and save harmless the Troy Cemetery Association and/or the Gardner Earl Memorial Chapel and
Crematorium from any and all claims and demands for loss or damages which may be made against them or either of them by
reason of,or connected with,the cremation of said remains and/or the disposition of said remains directed by me,whether such
claims or demands are, or are not wholly groundless, false or fraudulent.
It is requested that the following disposition be made of the cremains: (Check One)
( XX)Shipto* M. B . Clark, Tnc . '27 Saranac Ave . - T kP Placid , N Y. 1 946
The undersigned hereby authorizes the Crematory to deliver the cremains Via REGISTERED U.S. MAIL and agrees to
assume all liability for any damages that may arise from any cause growing out of said delivery and to indemnify and hold
harmless the Gardner Earl Memorial Chapel and Crematorium and/or the Troy Cemetery Association from any and all
claims related to said shipment. The undersigned also agrees to pay the charge for such delivery.
( ) To be called for
( ) Inter in "Oakwood" Lot No. Section Owned by
( ) Place in "URN GARDEN' Location No. Inscription
( )Place in Crematory Niche No. for month(s) Year(s) Perpetuity
( ) Dispose of the Cremains
WITNESS: . . ..... . . . . .... . . . . Signed:/� ' ' " :•� f . . .. . .. . .. . ... .. . . .
Address: .. 2?..Saranac Avenue Address: .Qla ,Military„R,oad. . .. . . .. ... .. . . .
city:. . . . .La.ke. .P.1aCi.l1 .. ...State..NX.. ... .. .. . City:lake. .Placid ...State.UY.. . ...zip.12946
... ... . . . .... . .... . .. .... .. ... .... .. .. . .. .... . . ... .. . . .. . . .. . . . .. . . . . .. .. .. . .. . .. .. .. .. . . .. . .. ... . . . . .. . . .. .
Cremains received by Date
Address:
Prices Effective March 1988
CREMATION,ADMINISTRATION COSTS AND RECORDING FEE adult$130.00
Children (Age 13 months to 12 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00
Infants (Stillborn to 12 months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00
Additional Services
Temporary Cremains Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carton & Pacldng Fee for Shipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Included above
Registered Priority Mail With return receipt . . . . . . . . . . . . . . . . . . . . .
CremationCase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00
Storage of cremated remains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . per month 2.00
Perpetual Memorial Niches for Cremated Remains. . . . . . . . . . . . . . . . . . . . . . . . 400.00
Receiving Room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850.00
UrnGarden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975.00
TERMS: All charges must be paid upon placing of order or at the time of Cremation.
BURIAL PERMIT AND THIS AUTHORIZATION MUST ACCOMPANY THE REMAINS AS
NO CREMATION WILL TAKE PLACE UNTIL THESE RULES ARE COMPLIED WITH.
The Gardner Earl Memorial Chapel and Crematorium
operated by
TROY CEMETERY ASSOCIATION
The Gardner Earl Memorial rial Chapel and Crematorium
operated by
TROY CEMETERY ASSOCIATION - - "OAKWOOD"
PHONE 272-7520 CREMATORY--OAKWOOD AVE. TROY, N. Y. 12180
AREA CODE 518 OFFICE—COR. 101ST ST. AND 7TH AVE.
AUTHORIZATION TO CREMATE
No....................................................... 1988 Date.....Feb......21......1992......••--........................
Name of Deceased .................Climena..l)<f.......Kiko.ff...................._................................._......................Sex.._..F..emale.......................
Residence .....................Uihlein..Mercy Center, Lake Placid N . Y . _
............................................
City or Town State
Single................................. Married................................. Widow.....X....................... Widower.............................. Divorced......................
Age.........................................9-3.. Years...................._.................... Months.......................................... Days
Place of Birth ..........V!.Um raglan......V.l........................................................................Date of Death....V1.9192.................
......_
Place of Death .........U. hle n..der.cy....Qenter.......Lake...�.lucid.,...N.,....X..................•--...-•---................--•---.......---..................
Street, City and State
Name and full address of nearest living relative or name of person Authorizing Cremation
_Robert Wkgff...... Q.l ..f\![ . . .Waxy.... oaa............. akae....1' .ae. . ...... +....X..:........................................
-•-- ... .... .... _...
Name Street, City and State
Relationship to Deceased....................................... Qn.......................•
Medical Attendant ....H......Douglas Wilson, M. D . Lake .Placid.t.. N. . Y...............................................
Name Street, City and State
Cause of Death ._. Natural
Name of Funeral Director lYI.....H. Clark,....Inc........27....S ax.anaq,.Aa dstate a ....Y.._.....
12946
Cremationon..........................................................................the----.....-----..........................Time of arrival ...........................................................M
The Gardner Earl Memorial Chapel and Crematorium and/or the Troy Cemetery Association is not responsible for errors
from phone orders. Remains will not be accepted for Cremation unless delivered in a combustible casket.*
(*Corrugated cremation cases must have bottom board capable of supporting 350 pounds)
The association reserves the right to refuse cremation when the remains are in a casket mad,: of fiber glass, plastic, metal or
other incombustible material; OR any incombustible material or substances placed within the casket that would be injurious or
damaging to the cremation chamber or the operator thereof.The funeral director in charge of the remains will be held responsible
for any damages caused by disregarding the above restrictions.
Hours are from 9:00 a.m. to 4:30 p.m. Monday through Friday, Saturdays until 12. No cremations will be performed on
Sunday or Holidays, however remains may be received on these days by special arrangement without additional charge.
SERVICES AVAILABLE IN GARDNER EARL MEMORIAL CHAPEL BY APPOINTMENT AND WITHOUT
CHARGE
NOTICE
"Some heart pacemakers can be dangerous when placed in a cremation chamber.If the pacemaker is not removed,the
family shall be responsible for any damage resulting and the crematory will not be responsible or accept any liability
under those circumstances.