Briano, Joseph own v ueenj tcrr.
riNE VIEW CEMCTERY,nd CREMATORIUM
QUAKER ROAD, QUEENSQURY, NEW YORK 12801
(518) 798.4 72G
(518) 79J-9777
Funeral Di[ictor 0�, /f AAA
ii Case No. # CZC20
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Time Crern<ilion Completed ,3
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
do
CREMATORIUM
t
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777 5
AUTI1ORIZATION 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:
SHEILA B. GILLINGHAM Female
Name Sex
40 Priscilla Ln. , Schenectady, N.Y. 12306
Street ;2 J�
City (State) Zip Code
who died on 20th. day of July 19 92
at Ellis Hospital, Schenectady, N.Y.
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Robert J. Gillingham Sr., 40 Priscilla Lane, Schenectady, N.Y.
Name Address
Relationship to the deceased Husband
Name of the funeral home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased JnMor 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.
W4n4h�461
ignat o Relative or Legal Rep.
Address Address
Signed on this date July 20, 1992
DISPOSITION 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
i. 'rhe crematorium will be open for cremations 5 cloys 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 reasen'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:
. f
Adult �lbs.vo
Children (age 13 months to 12 years)
Infants (stillborn to 12 months) $50.00
JoUll't U GL�e`2:S GGNI.�
rINE VIEW CUACTERY ,nd CREMATORIUM UU
QUAKER ROAD, QUEENSOURY, NEW YORK 12801
(518) 798 4 72G
(518) 79:3-9777
Funeral Dirictor
I J.n me j `J Tl��,�/ ��.�,�I /t��/y /1 Case No
UaLe of Cremation
Tim CremaLion Started ���� Zz OLD �
Time Cremation Completed
of Container d
d
Ae Cook ,20 L)d
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 )
/933-G? `� 31r0'Z:1 KY4 /�1. Y- A0,?b
(Street ) (City) (State) (Zip Code)
who died on day of c'2l 1917
at frl 147 � IV
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation : �` �/J
0. 2rcie 6 C f� 3 Caw- Cur 1. l�k+4c�ro
(Name) (Address) -7'-
Relationship to the deceased
Name of Funeral Home 'Ccx (r Ke?Un �/�•
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrangA
for the cremi.. ion 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, falser////�//yam fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: �3' �`
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. N. s, yrafoam 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 $19. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult $155. 00
Children (age 13 months to 12 years) $90. 0O Infants (stillborn
to 12 months) $50. 00