Wells, Gilbert 50"ll'i U
f IPJE VIEW CEMETERY and CREMATORIUM
QL►AKFR ROAD, QUEENSQURY, NEW YORK 12801
(518) 798 4 72G
(518) 793-9777
Funeral Dirictor
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Dale of Cremation
Tints CremaL-ion Started �d !('00
Time Creakit ion Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
�
CREMATORIUM PZ1
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTIiORIZATION TO CREMATE
'f lie undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
GILB-UZT H. WELLS Male
Name Sex
Route 8, Wevertown, N.Y. 12386
Street City State
Zip Code
who died on 12 Th. day of April 19 92
at Glens Falls Hospital, Park St., Glens Falls, N.Y. 12801
%riacel Address ——
Name and address of nearest living relative or name of person authorizing cremation:
!:rs. Lois Secor, Box 52, Wevertown, N.Y. 12886
Name Address
Relationship to the deceased Daughter
Name of the funeral home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased XwDot 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 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.
Witness Signature of Relative or Legal Rep.
Box 45, _�ia�nond Point, N.Y.
Address Box 52, Wevertown, D .Y. 12886
Address
Signed on this date 13 Th. Day of April, 1992
4 DISPOSI'l'ION 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 clays 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.
:1. 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
lline 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 r/SS.ao
Children (age 13 months to 12 years) $10.d0
Infants (stillborn to 12 months) $50.00