Bohlman, Jean T01+N O� QUEEVBU9?(Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6 A &,C' ;rd
Name T'jc- w Case 11 01'�3 F
Date of Cremation '�!�
Time Cremation Started 7♦Ee z ,,&4 1
t
Time Cremation Completed l �lff �fl1n)
Type of Container
Remarks :
-Y.3 Arm
jaxrM f
r
tbiaN t1E bUEENstlUtty ���
PINE VIEN tEMEIEhY f
t"F-MntUn I UM
Quaker Road, Queen4bury, New York 12804
Phone (518) CremAtOriUA 745-4477 or if no answer
CemetOry 745-4476
nuMu11IZnt10N tO CREHnTF-
the uhdersigned request 's and Authorizes Pine View Crematorium, in
accordAnce with and sub,j@ct t(i itt Rules And Regulations to
cremate the remains of:
Jean Eloise Bohlman Female
(Name) (Sept)
41 Peggy Ann Rd. Queensbury, NY 12804
(Street ) (City) (StAtb) ( Zip Code )
who died on 9th day of June 19 96
at 41 Peggy Ann Rd Queensbury, NY
(Place) (Addre44)
Name and addre44 of "tar@st living rtlativ@ or "Am* of person
Authbriting cremhtibn !
Mr. Walter Rahiman Al-P-egc*-Ann Rd
(NAfne) (Addrl49)
Relmtioh%hip to tht detodkod- Hu-hand
Nang bf punerAl Nome ca
iMPbninNTe
went that to the befit Of my khowledgl, the deceased has or
hA4 tlb pot6#4ker ih hips br her bbdy, (Circl # une)
I tertify that I hAV6 th4 full pbNer and authorization to arrange
for the crltmAtibn of the I-00Ain4 And to dirtct the dispo4it1on of
th@ cr@MAtild r@MAih64 thAt any peh4bhA1 pb4g644ions have either
both reAbvtd or may bo de4trby@di And agirtt to prbt@ctt defend
and Lave harmless Pine View CroAAtbrium front any And All claims
and demands for loss or dAMAg@4 whith may be made Against them by
re940n of or tohn€eted with th# trrmAtibn of Said remains as
directed, whether Ouch e1#144 br dfmbnd4 Ar• or are not wholly
groUnd1e44, false or frAudulbnt:
68 Main St Hudson Falls NY 12839
(Witne4s) Mddrots)
Peggy Ann Rd . , Queensbury, NY
(Signature of R@14tive br LlgA1 Rtp. and Addre4s)
Signed on thi4 dAtt !
b i spOs l t t uN tlt= C nEMn l E U
I hereby direct Pine View Crematorium to dispose of t),e cremated
remains as follows :
Mail to
Other arrangements - please specify :
If pulverization of cremate remains is requested, check here
POLICIES, rIULI=S nNU nEsuLntiUNS
1 . The crematorium will be open for cremations 5 days a wool(
7 :00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or Sunday
arrangements can be made for Saturday. Prearrangements
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pino
View Cemetery, Uuat<er Road, Town of Uueensbury.
3. nn authorization for cremation properly signed by the nearest
nomt of kin or other authorized person stating that they do havo
the power and authority to arrange for the cremation of tt,r
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 Pi ,,-
View Crematorium from any and all claims and demands for loss nr
damages which may be made against them by reason of or conne!-t -d
with the cremation of said remains and/or disposition of s-11d
remains as directed, whether such claims or demands are, er, arms
not wholly groundless, false or fraudulent. This authoriz,►- i —,
in addition to a regular burial permit must accompany tti(?
remains.
4. A11 remains must be hneased in a casl(et or suitable alternate
tontainer. Cachets and tontaiiners must be of combustible
material . No styrafoam or plastic containers will be accepted.
S. The question relative to tardiac paceMahers must be ans►+v-1
on tho authorization to cremate form before the remains will t,t-
accepted.
6. Unless other- arrangements are made the 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 120. 00
Charge for this set-vice.
Cremation, Administration Costs and Recut-ding Fee : Adult $ 175. 00
Children (age 13 months to 12 years ) t100. 00 Infants • ( stilibor-n
to 12 months ) 460. 00