Peskin, Malcolm Jown olQueenilary.
RitlE VIEW CEMCTERY avid CREMATORIUM
QLfAKF.R ROAD, QUEENSDURY, NEW YORK 12801
(518) 798 4 726
(518) 79;3-9777
Funeral D i r i c t o r A_Z006 )rxlyy,,=��--�,
t�,►ne �/� ,/�9�9,C �Q,�/b? 1�,C f1'i IS! Case No.
UaLe of Cremation
'I'inM Cremation Started
r
Time Cremation Completed
P c ntii r.k s
t
DISPostl'IOr 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 RHGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday.
No Holidays nr Sundays, arrangement,, ccin 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 reasen'bf, 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 rl6S.ae
Children (age 13 months to 12 years) $00.00 !
Infants (stillborn to 12 months) $50.00 j
4
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road
b
Phone (518) Crematorium 7 8-4726orrif no answer Cemetery 793-9777
AUTHi
'f I:e undersigned requests and authorizeRPineTVOewTO e REMA x'B
subject to its Rules and Regulations to cremate the remains of: ' �n accordance with and
Malcolm L. Peskin
Name Sex
10715 Toronto Lane,New Port Riche Fla. 34654
Street City State
Zip Code
who died on 75
day of May 19 92
ht "7-r_d.Hez3it.(1 Center,Warrensburg,NY
Place Address) ——
Name and address of nearest living relative or name of person authorizing cremation:
Ann T. Peskin
Same as Above
%Name Address
Relationship to the deceased Tnlife
Name of the funeral home Alexander-Baker F.H.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as 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 cremation of said remains
as directed, whetF er such claims or demands are, or are not, wholly groundless, false or fraudulent.
Wit ess22. c
c" ,
ignature of Relative or Legal Rep.
•Warrensou'c NY
Address Same
Address
Signed on this date