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Fish, Glenn TURN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director__���� y Name jj e i (�• Z /�/X /— !S Case # �J Date of Cremation / r -7 Time Cremation St art ed _ !Y i Time Cremation Completed f�2, Type of Container ����/ �3��� GJ�`S,G� !�/� �/jl•C�dj�] Remarks : gsPIM ' P�M 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: 00/' Fws Gt'�r Z�S& (Name) (Sex) (Street ) (City) (State) (Zip Code) who died on �U�- ' day of 199'-Z- at /T!1_7/ r,�i'liL (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : (Name) (Address) Relationship to the dec ea se d Name of Funeral Home 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 crem�L: 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, false or fraudulent. (Witness) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date: 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 f18. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $155. 00 Children (age 13 months to 12 years) $90. 00 Infants (stillborn to 12 months) $50. 00 ��e�,A C EMATION REQUEST To. U�erv5�v��/' Permit No. _______ Dated ---Apri 1_10 OLIMD"CIMOXT ----- 19_85 ORIUM Operated by: RA errue �j AiQ 61 z w` C? — T ��'Q��us 6Ltr�/ ray 4 The undersigned hereby requests and authorizes, in accordance with and subject to your rules and regulations as well as those of the State of New York to cremate the remains and casket containing same of ______________. Glenn W. Fish ------------------------------ who died at on the __-_� _ �./ - ----- day of ------------ --Pc��--_-------------------------------- 19_ Z and certifies and represents that he or she has the right to make such authorization and agrees to hold the Crema- torium, Funer?meFuneral Director harmless from liability on account of said authorization. Witness: (Signature of relative or Legal44 - ~ --�.� Address----Box 24 Cit Ri arius Funeral Director-- ___-- - - - - _----__ y----_--P________________ State__New-York - Firm_ �'-----�`_-- - -------------- - ------Wife----------------------------- (What Relation to Deceased or Authority to Sign) INSTRUCTIONS Disposition of Cremains 0�11 ez� ...... ------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------- ------------------------------ Authorized b Received the Cremains of the above named deceased this _____________ day of ------------------------ 19---- Signed ------------------------------------------- INFORMATION FOR CREMATORY RECORDS Name of Deceased Glenn W. Fish ..................••• .........f. ........................................................................................................................................... Late Residence i ?.�.��Y 1 V� �..... ....................................................... ............... ............................N.... ....................................................... Place of Birth Cor t landa New York .................................... .................................................................................................................. Placeof Death .........Q.....'<..,.5.......�` 5...........��.................................................................................................................. Date of Birth May 5, 1910............................................................................................................................... .................................................... Date of Death �....... ...../. ........�. ..... �........................................................................................... Age: Years .......0... ...... Months ................................ Days ............................ Father's Name Deceased .................................................................. .................................................. Deceased -- %�..�'.4r-............./..All Mother's Name ...... .................................................... . Married ...... Widowed Divorced ................... Single ................... Name and Address of Near Relative Authorizing permission for Cremation ....... f/......... /..-5..:.1.......................... ................................................................................................................................................................... yFuneral In ........................................................ Da ....................... Date ................................. Time ................................. �` ++ i Funeral Home Name ........`:::.4..24:. .i�.l-.....``......`G..... ......... ./.... n:: :............................ ... J, c: vac !..... 1►. r—............i 'r:. '.�...../.. .. .�� .............................. Address ........ ................... CREMATORY RULES AND REGULATIONS A request for cremation must accompany the remains and be properly signed by the nearest next-of-kin or other authorized person, in addition to a regular burial permit. Arrangement for disposition of the cremains must be made on the request form. Any cremains to be disposed of by the crematory cannot be reclaimed after two years. Remains will be received on a seven day a week basis between the hours of 8 A.M. and 5 P.M. by appointment only. > /�'`.e The charge for cremation ' _ ng working hours is / 0 which is payable on arrival. All remains must be encased in a casket or suitable container. (NO NON-COMBUSTIBLE MATERIAL WILL BE ALLOWED)