Cary, Elizabeth TOWN OF QUEEVBU_' �Y
PINE Y',:ZW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C o�A Wc�/X
(�
Name �C.// / cqv Case
Date of Cremation, Z6
Time Cremation Started—,
�„
r
Time Cremation Compl^et edn�� �-�
Type of Cont in r�7 f EP_1(/x "_t'Ij
y �
Remarks :
c
i
I
t oWN W Utwt"9140fly
PINE VI04 C:EMEtEt1Y
a
C"Emn1uRIUM
Quatker Road, QueehtbUry, New York 12804
Phone (518) CremAtoriUA 745-4477 or if no answer
Cemetery 745-4476
AUtNu"imtluN to CREMATE
The uhdersigned request 's and Authorises Pine View Crematorium, in
accordAnce with and sub,j@ct t(i itt 001@s And Regulations to
cremate the rOMAins of :
Fi t Kzrjon r Fenale ---
(Name) tSex>
54 14i1 1 js�ms StI-set fl
(Street ) (City) (Scat@) ( Zip Code )
who died on 11th day of x2y 19
at
(Place) (Adds-044 )
Name and addr#44 of hearegt living relative or nAm6 df person
Authbrizing cremAtibh :
MrQ- Marilyn Caputo
M lnb) (Addy@fs)
Relatiohship to th§ detfgtod
Nang of l'unerAl Home
6arleban Funeral Home bra.
i MPbntflNt:
I represent that to the bast of my know1*dge, the deceased has or
has rb pat#*gk@r ih his br hot- body: (circle One)
I tortify that I have th* full powot- and *uthori2Ation to arrange
for the cremation of the j,-#* sin4 And to direct the disposition of
th@ cr#MAt@d f-OMAihst thAt ahy plh3bh�►1 potW644ions have either
b#oh r@Aovbd b.r may by destrbyedt And agr@p to protbct, defend
and §ave harmless Pine View Ci-##Atorium from any And All claims
and domandt for loss or dAM49#4 which may be made Against them by
r-eAson of or tohngctod with the ti-OmAtion of Paid r@maiins as
directed, whether 'such claims br dldand+i Are or are not wholly
groundl@sss false or frAudul@nt:
(Witnt►ss) (Addrea<s)
� I
ASignat re of elAtive or LlgAI Rpp. and Addre3s )
p
Signed on thi3 date :
I)i spos i t i UN OF C REMf1 l E t) tir:Mci t Ns
I hereby direct Pine View Crematorium to dispose of the cremater
remains as follows :
Mail to
Other arrangements - please specify !
If pulverization of cremate remains is requested, check here l�
PUL i C 1 ES, ftULIEs nNU 11EGULA t-I ONS
1 . The crematorium wi l 1 be open for cremations 5 days a raoo►<
7 :00 A. M. - 3!30 P. M. Monday-Friday. No Holidays or Sunday-. ,
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 the pimp
View Cemetery; Quaker Road, Town of Oueensbury.
3. An authorization for cremation properly signed by the nearpat
nomt of kin or other authorized person stating that they do havp
the power and authority Ed Arrange for the cremation of thr,
remains and to direct the dispbsition 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 nr
damages which may be made against them by reason of or conrnect —i
with the cremation of said remains and/or disposition of sarri
remains As directed, whether such claims or demands are, or- ar-r
not wholly groundless, false or fraudulent. This authorizit- t ,—
in addition to a regular burial permit must accompany khr?
remains.
4. All remalinS mutt by encased in A casket or suitable alternate
container. Caskets and tontainerf must be of combustible
material . No styrafoam or plAstit containers will be accepted.
5. Tho question relative to tardiac pacemakers must be ansr+v, t
bn thr Authorization to cremate form before the remains will I,r
accept fed.
6. Unless dthet- arrangementS are made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremation
to the funet-At 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 ) i100. 00 Infants ( stillborn
to 12 months ) t60. 00