Perkins, Allen 7Or14N OF QUEEVBU-IPk.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director 14CDXoL �'�r`//�
Name -VR a,E"/1( Case # p
Date of Cremation /02 —dD — / a
Time Cremation Started
Time Cremation Completed &"fed
Type of Container /'e /t ,0&0/9X. /s
Remarks :
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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 R. 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. No styrafoam or plastic containers will be accepted.
5. Thee question relative to cardiac pacemakers must be answered
OK the authorization to cremate form before the remains will be
a'dCept ed.
6. Unlesi•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. 00 Infants (stillborn
to 12 months) $50. 00
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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 reauests and authorizes Pine View Crematorium, in
accordance with and sub)ect to its Rules and Regulations to
cremate the remains of:
Allen T_ Perkins Male
(Name) (Sex )
Rt. 8 Hague New York 12836
(Street ) (City) (State) (Zip Code)
who died on 27th day of December 19 92
at Glens Falls Hospital , Glens Falls , New York
(Place) (Address)
Name and address of nearest living relative or name of person
auth rizing crem i n :
(N me) (Address)
Relationship to the deceased son
Name of Funeral Home Wilcox & Regan funeral home
IMPORTANT:
I represent that tc the F„sa o f .__. .,
� .-j r% IEuge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorizatipn to- *arrange
for the cremation of the remains and to direct the disposit:)oL" of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protoct, d4fend
and save harmless Pine View Crematorium from any and alf"'CpIaims
and demands for loss or damages which may be made ag2rinst:' jtem by
reason of or connected with the cremation of said rem gns as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Ad s
(Signature of Re ative or Legal Rep. and Address)
Signed on this date : DeceMber_ 28, 1999