Johnson, Kathryn T- O- " VN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1 �_l \ ��j N S I&N,%8C a s e # l
Date of Cremation - 3
Time Cremation Started
Time Cremation Completed
Type of Container 1AAl'?0 1420Qa C EWQ +
Remarks :
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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 requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Kathryn S. Johnson Female
(Name) (Sex )
821 Daniel Shays Highway Athol, Ma. 01331
(Street ) (City) (State) (Zip Code)
who died on 9th day of March 19 96
at Quabbin Valley Health Care 821 Daniel Shays Highway Athol, MA
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Patricia Travis 39 Ferry Iane Stillwater, NY 12170
(Name) (Address)
Relationship to the deceased Granddaughter
Name of Funeral Home Flynn Bros. Inc. 13 Gates Ave. Schuylerville. NY 12871
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
as n ipacemaker 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
gr undles fa afuldu1ent.
13 Gates Ave. Schuylerville, NY 12871
i n s)� (Address)
39 Ferry lane Stillwater, NY 12170
(Signature of Relative or Legal Rep. and Address)
Signed on this date : March. 10, 1996
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify : Will Pick Up
If pulverization of cremate remains is reouested, check here xx
POLICIES, RULES AND REGULATIONS
1. The crematorlL.im 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 t11F. 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