Rabine, Terry TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSDURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director c qt� e
Name , li K �, 1= Case # 3 D
Date of Cremation / k
Time Cremation Started j 1c)
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Time Cremation Completed J()
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Type of Container e iO ,G G� rc4 e- a,,� Th
Remarks :
141 Ai N ,GL)yVX-R 0/4
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tUWN or tiUEt NsHUrty
PINE VItW CEMEIElIY
CtiEMntUR IUM
Quaker Road, Uo0on4bury, New York 12804
Phone (518) CremAtoriUA 745-4477 or if no answer
Cemetsry 745-4476
t1UthURI ZnttUN to CREMI1tE
the undersigned request 's and Authoriies Pine View Crematorium, in
accordAnce with and sub,j@ct td itt nul #t And Regulations to
cremate tho rk*Ains at!
Terry Lynn Rabine Female
(Name) (SPA)
365 Pacific -Dr.. Lake Havasu City, AR 86406
(Street ) (City) (State) (Zip Code )
who died on 15th day of ALg»st 19 9r
at
(Place) (Addrls�l
Name and addr#49 of hear@gt liviMg rrlAtive or nsm* of person
Authbriting crembtibh!
Mr
(NA(ne) (Addres,)
Relatiahship to the deteatod
NaMe Of Iuneral Home
jMPURTnNT3
agent that to the bolt of MY Nnowledgl, the deceatfd has or
has rib ateaaker ih hit bh hot- bbdy: (Circle Une)
I tlrtify that I hav6 this full power and authorization to arrange
for tho crtmatibn of the t-409in3 And to direct the dispasition of
the crobattd rpMiAihs; thAt Ahy peh4bfiAl po44644ions have+ either j
beeh treAovbd Or *Ay by dpktrbyedi And agi-60 to prot6ct , defenri
and save harmless Ping VieW CrpAdtorium from any And all claims j
and d mand3 for loss or dAM69#j which may be made against them by
1^0640 of or corn€ctod with th# ti-pMstion of Laid remains as
direc edi whether such t19144 Or d#MAnd�4 Ar0 or are "at wholly
graU logs, fA so v frAudUlent:
68 Main St , Hudson Falls , Ny 12839
(Witness) (Address)
/ ° 365 Pacific Dr , Lake Havasu. City, AR 86406
� j
1� 7� if
(Signature of vRelativo Or LlgAI Rpp. and Address )
Signed an thi+4 date : 8/19/96
' I
DISPOSITION OF C"EMt1tEl) ar-m INS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please
If pulverization of cremate remains is requested, check here
PUL I C 1 ES, "ULES nNb I smn I I UNS
1 . The crematorium wi l l be open For cr-emations 5 days a woolf
7 :00 A. M. - 3:30 P. M. Monday-Friday. No Holidays 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 Uueensbury.
3. An authorization for cremation properly signed by the nearevt
neat of kin or other authorized person stating that they do hair
the power and authority to arrange for the cremation of I:h"
remains and to direct the disposition of the cremated remains,
that any personal possessions have either been removed or may bp
destroyed and agree to prbtect , defend and save harmless Pinp
View CrematoriuM from any and all claims and demands for loss nr
damages which may be made agairi§t them by reason of or connprtnfi
With the cremation of said remains and/or disposition of sa ►r1
remains as directed, whether such claims or demands are, or .are
not wholly groundless+ false or fraudulent. This authorizes,. , ,,.,
in addition to a regular burial permit must accompany tl»
remains.
4. All remaiins must by encased in a casket or suitable alternate
tontainer. Casltets and tontainers must be of combustible
material. No 9tyrafoam or plastit containers will be accepted.
5. Tho question relative to tardiac pacemakers must be ansr+v•
on thr authorization Ed cremat!► form before the remains will t,r-
accepted.
6. Unless dther- arrangemente, 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 $20. 00
Charge for this service.
Cremation, Administration Costs and Recording Fee , Adult $ 175. 1,710
Children (age 13 months to 12 y0ars ) $ 100. 00 Infants ( stillborn
to 12 Months ) 460. 00