Camp, Virginia TURN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ���`
Name ! OI�G //�/� eo �l & Case # �
Date of Cremation1�r
Time Cremation Started /
I
Time Cremation Completed Z ![ &A, i
Type of Container � j['J � tX�r�� �'�✓� �� �/T.4�
Remarks :
a -
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to _ r'r r7 GJ.-cw
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 Cemet.er-y, Quaker Road,. -Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other a'uthorized' perso'n 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 possessi_pns 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 maybe 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 bur-ial 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 $,20. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult $175. 00
Children (age 13 months to 12 years) t100. 00 Infants ( stillborn
to 12 months) $60. 00
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
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:
Vi rai n i a 8��3SS r Female
(Name) (Sex)
56 Pi e1 dgtone nri vP,GANSEV00RT Per Ny 12866
(Street ) (City) (State) (Zip Code)
who died on 2nd day of November__ 19g3_
at 56 Fieldstone Dr Gansevoort Ny 12866
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Mr. Steven Camp 56 Fieldstone Dr,Gansevoort ,NY 12866
(Name) (Address)
Relationship to the deceased �'�
Name of Funeral Home William J . Burke & Sons Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker i his o<jr bod (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
groundless, false or fraudulent.
(Wit ss) (Address)
(Signature of Relative or Leg Rep: nd Address)
Signed on this date : Zi lF F 3