Tryon, Sandra �O� OF QUEEVBU_' '
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director zy4ge//� s
Name Case # ®
Date of Cremations- 16;�` 9-3
Time Cremation Started
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Time Cremation Completed_g t 310 11:71� `
Type of Container � �6�/��j ���j���/�$� Q� �i5�,c�•���/
Remarks :
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TOWN OF QUEENSHURY �J
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 reouests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex)
hell e f ,--)
(Street ) (City) �(Sta ee) (Zip Code)
who died on �j� day of
at f - c7/1
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation : 4;e,
,&/
(Name) (Address) /
Relationship to the deceased + CIS/�f2i(XJ
Name of Funeral Homel A-4-14tIlA,S
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 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
ground ess, ralseyor fraudulent.
Wi ess) (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. Mondav-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. 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 f12r. 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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'Customer's Designation of Intentions'
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Name of Deceased:
Cremation: T//�f✓/cc� /Ci ( I/JPPns��r�/
( Scheduled Date) (Locati n
Manner of Disposition of Cremains :
[ ] Burial at [}C_l Return to Family
[ ] Entombment at [ ] Other ( specify) :
Disposition of Cremains Designated by:
( S4neL)—
A61W e 14 Ile v , Al
(A(:Ydr s s)
71n
(Telephone Number)
'Cremains which shall not have been claimed within 120 days from the date
of cremation may be d'sposed of by this firm, in the following manner
of disposition
f �! 3
Name of Funeral Director Signature of Funeral irector ate
AV-
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremains :
(Manner of Disposition)
`w (Location)
(Date)
Name of Person Making Disposition Signature Date