Merrill, Frances 1
rl�CJ� O,T QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QCT.°,KER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_c Qkh to L4
Name ERRACE,( j, E l �Case a '5�
Date of Cremation l 2 - Co
Time Cremation Started
Time Cremation Completed ��
Type of Container C'iAl� {{��Wf} out St C"gC'ei OF P�
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
(,luaker 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 :
Frances E. Merrill Female
(Name ) (Sex)
4 Parkwood Ave. Hudson Falls, NY 12839
(Street ) (City) (State) (Zip Code )
who d i ec on 8th day of ?larch 19 96
a{Glens Falls Hospital 100 Park Street Glens Falls, NY 12801
(Place) (Address )
Name and address of nearest living relative or namveaf person
authorizing cremation :
Mr. Harvey P. Merrill Sr. 4 Parkvood Ave.
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Ham arleton Funeral Home Inc.
I MPUR-i ANT
sent that to the best of my knowledge, the deceased has or
t:as "a acemaker 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
directe , whether such claims or demands are or are not wholly
ground ss, false or fraudulent. W('IoS6�"
, �
Witness ) (Address) / ?�3�
(Signature of Relative or L gal Rep. and Address)
Signed on this date :
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DISPOSITION OF CREMATED RFMnINS
I he-ehy direct Pine View Crematorium' to dispose of the cremated
remains as follows :
Hail to
Other- arrangements — pIPAse spec tfy : ___
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. 11. Monday--Friday. No Ho idays or Sundays,
arranr�rment � can be made for Saturday. Prearrangements by
tr2lepl. )r,e for acceptance of remains is necessary.
2. Pine 'Jier+ t r-r?matorium is located on the grounds of the r T".
View Cemetery, Quaker Road, Town of Queensbury.
3_ (In 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 dispositior, of the cremated remains,
tt-rat any personal possessions have either been removed or may be
Hestroyed 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.
�. r=ii _ remains must be encased in a casiret 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 answer-PH
on the authorization to cremate form before the remains will he
ar_cPpted.
6. Unless other arrangements are made the cremated remains 4+111
be mailed via Registered U. S. Mail within three days of crematirri
to the funeral home handling the service. There will be a $PO. nn
chargP for this service.
Cremation, Administration Costs and Recording Fee : Adult f175. 0n
Children (age 13 months to 12 years ) f100. 00 Infants ( stillbor-r
to 12 months ) $60. 00