Moss, Arthur f
TOq+N OF QUEEVBU-'P*,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Ci />/C��v 3/NF
Name 4g-7w1? xd 5d 5 Case
Dat a of Cremat i on
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Time Cremation Started v
Time Cremation Completed -
Type of Container C�dgP& /L.1/ c;Z/V,P/
Remarks :
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PINE VI�1� t:Et"iEtEKY
t"F-Hn 1 UR I UM
Quaker Road, Uueehsbury, New York 12804
Phone (518) CrematoriuA 745-4477 or if no answer
Cemetery 745-4476
nUttlonI zntION tU CRF-HnTE
The undersigned request 's and authorizes Pin* View Crematorium, in
accordahce with and sub,j@ct td itt Ru1 #4 And Regulations to
cremate the rtMAins of:
Arthur Harold [loss Male _
(Name) (Sek)
Apt. 4C Earl Towers Hudson Falls, NY 12839
(Street ) (City) (StAte) ( Zip Code )
who died on let day of July 19 96
at Glens Falls Hospital 100 Park Street Glens Falls. NY 12801
(Place) (nddt-#§§)
Name and addrt43 of heartgt living rtlAtivt± or hAmt of person
Authbriting cremAtibml
Mr. David Koss Vaughn Road Hudson Falls , NY _
(NAMe) (nddrtst)
FtelAtiohship to thb dects&kod Son
NSOV bf IunerAl NoMe rarlelon
>1 MPbRTt~1Nt
Bent that to the btst of ay k"owledge, the deceased has or,
hA±s hb ' a►CtAtAkph ih hit bt^ her bbdy: (Circlt Unt)
I ttrtify that i hAvt tht full poNtr and Authorization to arrange
for the crOmation of the remain+) And to dtrtct tht disposition of
tho ct-@@sold f-tMAihsi thAt dhV plrbbhAl pb§yltgions have either
bebh -@Oovbd or May be dp§trbY§di And agree to protect, defe—i
and §ave harmless Pint View CreAlAtorium from any and All claims
and deteandt for loss or dAMAg#4 whith may be made Against them by
reAt;on of or tohn@ctod with th# thlMAtion of Laid remains as
directed, whether such t14144 br dtdandt art or Are not wholly
gr d1e4e Alst, or frAudulent.
Carleton Funeral Home Inc .
(wit a s) (Address)
Hudson Falls , New York
(S gnature of Re tive or L6941 Rep. and Address)
Signed on th i 3 dat b t . Oq
96
U I SPt)S I T I UN Or C IiEMn?E l) Rr MCI I NS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as Follows -
Mai I to
Other arrangements - please specify :
IF pulverization of cremate remains is requested, check here
PULICtES, rIULP-s nND "EGOLnrIONS
1 . The crematorium will be open for cremations 5 days a wppi<
7 .00 A. M. - 3t30 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 Pine
View Cemetery; Quaker Road, Town of Uueensbury.
J. 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 thf-
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 Piria
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 -ri
with the cremation of said remains and/or disposition of sari
remains as directed, whether such claims or demands are, or arms
not wholly groundless# false or fraudulent. This authoriz0- i
in addition to a regular burial permit must accompany thr?
remains.
4. All remains must by encased in a casket or suitable► alternate
container. Casltets and tontainers must be of combustible
*aterial . No styrafoam or plastic containers will be accepted.
S. The question relative to tArdiac paceMakers must be anc%i— ,
on tho Authorization to cremate form before the remains will t'v
accepted.
6. Unless otheti- 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 120. 00
charge for this service.
Cremation, Administration Costs and Recording Feet Adult W 5. 00
Children (age 13 months to 12 years ) t100. 00 Infants ( stillborn
to 12 months ) 460. 00