McMurray, Wesley TOq+N Lnljrr QUEEVBUNY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name � me, Case #
Date of Cremation
Time Cremation Start ed / it 411b' A
,Q
Time Cremation Completed 16411,f7Ej !/tt"`
Type of Container y a-/Y-a
Remarks :
,41 r4i N 901fNIG-9 0.14 �M j
ALIN
to"N W t1tjct g#tjttY �+ �
PINE Vlttl CEMEIE"y
CtiEMgtUit I UM
Quaker Road, Qu@6n4buryt New York 12804
Phone (518) CremAtoriuA 745-4477 or if no answer
CemptOry 745-4476
nUTt1U"1znt1UN tU CREMnTE
The undersigned request 's and authoriies Pine View Crematorium, in
accordAncr with and sub,joct tH it3 Hulot And REgulations to
crematO th* r**A1,1s or '
W i, :S l � � L . M rye u Y � l --
(Name) I (Se►(>
(Stre0t ) (City) I (Stato) ( Zip Code )
who died on day of �J L� ne 19
(Place) (Addrl+l!)
Name and addre33 of hearpst living rrlati " or ng** of person
�uthbriiing creM�tionb
(Natee)
Relatiohlhip tb the deceased l 5 �-�✓
N a M b ner Komi; 0GC,r
1 MPO"t n"T±
l r! t to thin bl+�t of myttnowledgE, the deceased has or.
r+b pate�+�kei^ ih hie br hrr bbdVa on!)
1 tlrtify that 1 hAv@ th* full poNlr ,And Authorization to arrange
for thr crlrMAtion of the roroaln3 And to direct this disposition of
the cr-#Nat#d i-OMAIhs*
b JL-d1
(Witness) (nddreys)
C .
(Signature f elativp br Llg�►1 pp. and Address)
Signed on thi3
DISPOSITION OF Ct2EMA 1 EI) (tr=Mrl I NS
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
PUL I C l ES, "ULES AND f1E(3ULA t I UNS
I . The crematorium will be open for cremations 5 days a If
7 .00 A.m. - 3:30 P. M. Monday-Friday. No F(ol idays or Sund.ay'� ,
arrangements can be made For Saturday. Prearrangements I ,
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pinp
View Cemetery{ Quaker Rdad+ Town of Oueensbury.
3. An authorization For cremation properly signed by the near•ent
"omt of kin or other authorized person stating that they do havp
the power and Authority to arrange For the cremation of tt`f'
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 Pirip
View Crematorium from any and all claims and demands for loss nf
damages which may be made against them by reason of or cor,nectpfi
with the cremation of said remains and/or disposition of said
r@mains as directed, whether such claims or demands are, or are
not wholly groundless# false or fraudulent. This autl,oriza� �
in addition to a regular burial permit must accompany th"
remains.
4. All remains must be encased in a casket or suitable alternate
container. Casltets and containers must be of combustible
I(iaterial. No styrafogm or plastic containers will be accepted.
S. Thr question relative to tardiac pacemakers must be ancti—
on the authorization to cremate form before the remains will h,v
accepted.
6. Unless other arrangements are made the cremated remains will
be mat led via Registered U. S. Mail within three days of c rematiof,
to the funeral home handling the service. There will be a 420. 00
charge for this set-vice.
Cremation, Administration Costs and Recording Fee : Adult i175. 00
Children (age 13 months to 12 years ) ti00. 00 Infants ( stillborn
to 12 months ) 460. 00