Mead, Marjorie T014N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director V'w �� _
Namej'/1� ®/i / /1�1,� � Case # �
Date of Cremation
' tton r
Time Cremation Started
1 Time Cremation Completed / ! �
Type of Container
Remarks :
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From D D. SC-RGI :44E.0 0-
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TCUM OF CRJEENISWRY
PINE VIEW CEWTERY
i
CREMATORIUM
Quaker Road, OueertSburV, New York 128$4
Phone (510) Crematorium 745-4477 or if no answer
Clm4tery 745-447fs
AyTiORI TaY1ON To CIMMRTE
In
The ur.der-s•igned •'epuests and authoriseSRules vaRei Reiew 9ilatianst to
#Ccardance with and subject to its Q
e"M*te the remal"s eft rr
(Sex)
���- •
(Street) ^ram(City)
(St�►t c) (Z S C
who died
day of
o^
at (Place) (Address)
Name Ond address of nearest living relatsv• Or name of parson
authorizinq cremat:ant
(Address)
Relationship to the deceased
Name of Ftanerm I Home
1
t$Vm3pTaffC ks,owtecfgr• the dweva�ead has orI r•ePr•esent that to the best of my {Circle One)
no
as pacemaker in hi• or her body.
I certify that I have the full po►•er, and authorisation to srrn o
far the crlRatian of the resai"s and to direct the dasPOcitio of
• the cr�tmafed remains, that any prrsvrs[1 reeSetoioratrete defend
been removed ar ray be destroyed, and a9
and save harness Fine view Crematorium from any and all 016ims
and cserar,ds for loss or dosages which gray be mode aid them %
reason of ar connected with the ere•atin^ of so remains a
directed, whether
esuch
claims
or deeards a►^e or are not wholly
false
Aro (fleas•
�� (Address 3
�Witn�cs) 'J�
(Signatur. of RelitjvV or Legal Rep. and A.idrtss3
SiQnsd on this dot*:
I
JUN-07-86 18:04 FROM:K 1 NKO5 71 U241026tlb 1 u: r04L r-
r om DAV i U D.
CIS
Y
f t • r
DTSPGBTTIClN tW CREMATED REMAINS
i hereby direct ptne View Crematorium to dlsnos;e of the cremated
rew4kins as follows: _
nail to
pfhrr arranger4onts - please specify: -
If pu:verizslia� of creaste re+aains is rPneaested. cheek here
PUL Y C T ES. RULES AND RE6CiLPT I ONS
The creaat9r-l"V will be cos" for cremAtians 5 clays a week
7:00 a,th. - 3:30 �. re. MOndaY"Pr'tday• No Holidays or Sundays.
pre�errus+geaer+ts by
arr&ngemes+ts can be made for Sat%Arday.
telephone for ^Ccoptance of remains is neCPssary.
2. pine View Crematorium iS located on the grounds of the 01'.10
View Cemetery. puakel' Road. Tows, of Que*"$bn.Iry.
qn authorization for cremation properly signed by the noairest
3,
next of kin or Other authoei2v a^r=orn`osratthe cre+usCg that rlon defhthe
the newer` and alrtr+ority 4
r+emain+s and to di,"ect the disposition of the cremated r-amal"S,
that any personal possessions have either been removed ov^ way be
destroyed and agree to protect, defend and cave heraless Pine
View Crematorium frees any and all claims and demands
for
colots
tof
damages Khich coy be made agaoinst thew by o
ed
with the Cremation 0f. said remaiets arid/or disposition of said
remains as directod, whether such claims or demands are, or- are
not wholly grovnsdless, false or Fraudulent. 7l�is dutiiVr;ration
it addition, to w regular` burial peraL% must accompany the
remains.
4. all remain* oust be ences,rd in a casket ar suitable alternate
container. Caskets and Contas"er's must be of combustible
arterial. No styrafoam or plastic containers will be accepted.
• s, The questicrt relative tO eat"diae PaC*Ruahers must be 4"'tred
vn the authorisation+ to creanate form btforr the remains, will be
ace w pt od.
6. Unies• other arrangemer=tti are made the cr-emated remains will
be wailed via Rogiste*-ed U. S. Mail within three days at Cremation
to the funeral ;'+owe handling the service. Thcre will Or a iia• 0�
charge for this service•
CTewations Rder►i*+istrstios+ Costs and Recording Fee: Adult $155.®e
Chi Idrts'n cage 13 mo^tCne to iZ n
years) •10.00 Infants
tot 11lOprn
to 12 **nth*) 550.00