Buck, Mae I. TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director LA
tiName G`�1-T� � �L� I� "' �aye it ll�
Date of Cremation ` � 2`Z'
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Time Cremation Started 3 O h9- 4-1
Time Cremation Completed A O
Type of Container O'oy'1 0 C,
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Remarks :
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TOWN OF OUEENSBURY
DINE 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 request 's and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Mae Isabelle Buck Female
(Name) (SOM) —
Pleasant Valley, Infirmary Argyle, NY 12809
(Street ) (City) (State) (Zip Code)
who died on 20th day of April 19_ 96
atPleasant Valley Inf Route 40 Argyle. NY
(Place) (Addre44)
Name and address of nearest living rllativ# or name of person
Authorizing cremation :
Mrs Constance Mansell RR 1, Box 162 Schroon Lake , NY
(Name) (Addrt►ss)
Relationship to tho deceased Sister
Nam* of Funeral HomeCarleton Funeral Home Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has nb pacemaker in hit or her body: (Circle One)
I certify that I have tht full power and authorization to arrange
for the cremation of the remains and to direct this disposition of
the cremated ro*Ains•1 thAt ahy p0-4onal pottsissions 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 damagot which may be made against them by
reason of or connected with tho Cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
Carleton Funeral Home , Inc .
(Witness) (Address)
• ���� � o f ,�' ( ���� Schroon Lake , NY
(Signature of Relative or Lbg/al Rep. and Address)
Signed on this dates Ar,i
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
i. The crematorium will be open for cremations 5 days a weet<
7:00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or Sunday-,
arrangements can be made For Saturday. Prearrangements h�'
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 ttir
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 Pinp
View Crematorium from any and all claims and demands for loss of
damages which may be made against them by reason of or connect -rt
with the cremation of said remains and/or disposition of s.A1r1
remains as directed, whether such claims or demands are, or---ire,
not wholly groundless, false or fraudulent. This authoriz�1, i ••,
in addition to a regular burial permit must accompany k11-
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 ancti.,r �
on the authorization to cremate form before the remains will t,e
accepted.
6. Unless other- arrangements are made thq 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 ) $ 100. 00 Infants ( stillborn
to 12 months ) t60. 00