Robinson, Samuel 50tal O uee` i ar
ritlE VIEW CENICTERY and CREMATORIUM
QL►AKFR ROAD, QUEENCQURY, NEW YORK 12801
(518) 798 4 726
(518) 793-9777
Funeral Dirictor
I1•�ui� it i)�, ! /AML� c�1 1A, 5- ,4 Case No. 02
UaLe of Cremation
Tints Cremation Started �i ��—/711
Time Crewt ion Completed L1 /r
7}E of Container
1?cnvi r.k s moel/Al
DINPOSITION OF CREMATED REMAINS
--� I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mnil to
Other arrangement - please specify:
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IO RAS_46�6_s:
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
Pine 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.
fi• 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 $1000 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 OURRNHUURY .
PINT? VIEW C;RMRTRRY /
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'rhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
�S� �,� R ,
Name
Sex
Street
City State Zip Cod
who died on
day of
,��------19—a
at A
dress
Place
Name and address of nearest living relative or name f person authorizen cremation:
Name
Address
Relationship to the deceased d
Name DAMES F.SINGLETON,INC.
of the funeral home 314 Bay Road
IMPORTANT: '
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
remains and tq direct the disposition of the cremated remains, that any personal possessions
from any and all claims and demands for loss or damages which
have either been removed or may be destroyed, and agree to protect, ess
of the
Pine View Crematorium, P , defend and save harml
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.
Witn ss
Signature of Relative e o ggal Rep.
Ad
119
A d ress ,
Signed!onthis date