Sturges, Kenneth 70`UN of QUEEVBUNY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorL�f
Nam e ���is C a s e # �- !J!
Date of Cremation —,,2
Time Cremation Started
Time Cremation Completed I d110 r
Type of Container �' /1 .�w��� AS/
Remarks :
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D I SPOS Y T 1 ON OF CREMATED REMAINS
I hereby direct Pine View Crematorium to disoose of the cremated
remains as follows :
mail to
other arrangements - please specify :
If pulverization of cremate remains is i,equested»Ρ check here L../
COOL t C YG$y RUI..ES AND REGU(_PT 1 QN$
1• The Crematorium will be ooen for cremations 5 days g week
710.0 A. M. w 3.30 0. M. Monday-Rriday, No Holidays or Sundays.
derangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary.
2. pine View Crematorium is locatfd on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation
next of kin or other authorized properly signed by the nearest '
the power and authority to arrasngeonfor atthe cremation ing that they do
have tha
r#M-Oros and to direct the disposition of the cremated remains,
that any personae possessions have either been removed or may be
destroyed and agree to protectf defend and save harmless Pine
View Crematorium from any and ell Claims and demands for loss of
damages which away be made against them by reason of or connected
'with the cr9gAtian of said remains and/or disposition of said �
rwemaim% as directedv whether not additi ®raundlefs, such claims ar demands are, or are
in addit false Or fraudulent. This authorization
remains. �on to a regular burial permit must accompany the 4. All remains Must, be encased in a Casket Or suitable alternate
container• Caskets and containers must be of eoatbustible
material. N.' %+ yrafoam or plastic containers will be accepted.
The question relative to cardiac
On 'the authorization to Cremate form before the remoin ers, mustns answered
. 8ccePt ed.
�• llr+ltsa other arrangements Ora made the Cremated remains will
be availed 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.
CrpMation, Administration Costs and ReCprding Feet Adult slS�. �BO
Children (ag# 13 months to 12 year$) $90. 00 to 12 Months) $50. 00 Infont$ (stillborn
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TOWN OF UUEENSBURY
p I NE V 15W CEMeTERY
CREMATORIUM {
Quaker toad, Queensbury, New York i2804 v
Phone (518) Crematorium 745-w4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
'rho undersigned requests and, authoriXes Pine View Crematoriurtt, in
accardanco with and subject to its Rules and Regulations to
cremat® the remains ofi
(Name) (Sex)
.., a .
c ta � X r a c
(Street) (City) (state) (Zip Cade)
who died on ..._,.day of �-Y--
at
(place) (address)
Noma grid address of nearast living relative or name of person
authorizing cremations
(Name) r (Address)
101
Relationship to the deceased
Nam' of Runeeal ftme— .���
I MMRYANT#
I represent that to the lest of my knowledge, the deceased has or
has no pacemaker in his or her body, (Circle One)
1vertify :that I have the gull power and authorization to arrangh
;4or. the creme-.ion of the remains and to direct the disposition of
the Cremated remains, that any personal possessions have either
bblfi ' removed or may be destroyed, and agt^*e to protect, defend
-, nq save harmless Pine View Crematorium -from' any and all claims
0d; deoands for loss or damages which may be made against them by
re4son of or connected with the cremation of said remains as
directed, whether gush claims or demands are or are not wholly
groundless, false or fraudulelht.
NI
.:(W' n s> ddress)
(S#gi+�►ture of Relative or Legal Rep. and Address)
Signed on :this . dates �.,..