Kingsley, Edward Sr. TOWN OF QUEEVBU.Iky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � i� ��1(
Name .1/ etl. Case #
Date of Cremation--3--�` - '
Time Cremation Started t
f ) `
Time Cremation C',ompleteed &
Type of Container d 02E
Remarks :
1=14:5,�
toWN Or hUEt=NSBURY l S�
PINE VIEW CEMETERY
4
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATfON TO CREMATE
The undersigned request 's and authorizes Pine View Crematorium, in
accordance with and subject to it* Rules and Regulations to
cremate the remains of:
Edward Thomas Kingsley Sr. )tale
(Name) (Sex)
54 Ogden. Road Queensbury, NY 12804
(Street ) (City) (State) (Zip Code)
who died on 29th day of April 19 yf,
at Glens Falls Hospital 100 Park Street Glens Fa11R, NY UAW
(Place) (Addre+44)
Name and address of nearest living relative or name of person
Autharizing cremation:
Grace Kingsley 54 Ogden Road Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Carleton Funeral Home Inc.-
IMPORTANT:
I re r to the best of My knowledge, the deceased has or
as no pacemaker 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 crenated 1-06aihs, that ahy ptrsonal posslssions have either
been re:iovtd 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 d#mAnd4 art or are not wholly
gro 1 ss, f se or fraudulent.
Carleton Funeral Home , Inc .
(Wi nL+ss) ` (Address)
Queensbury, •NY
(, 'gnature of R lat a or g/ Rep. and Address)
Signed on this date : �' 7� (�-
DISPOSITION OF CREMATED Rr:MnINS
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
1. The crematorium will be open for cremations 5 days a weei<
7 :00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements t",.
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of tho Pimp
View Cemetery, Ouaker Road, Town of Oueensbury.
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 thr,
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 Pirio
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 authorizl- t —,
in addition to a regular burial permit must accompany tl+r?
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.
S. The question relative to cardiac pacemakers must be ansv+e, r +
on the authorization to cremate form before the remains will by
accepted.
6. Unless other- arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within throe 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 t175. 00
Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn
to 12 months ) $60. 00