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
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Time Cremation St art ed _ !Y
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Time Cremation Completed f�2,
Type of Container ����/ �3��� GJ�`S,G� !�/� �/jl•C�dj�]
Remarks :
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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� ......
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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)