Mosher, Walton itio" Ur buttNSAUOY �
PINE VIOLA CEMEtE12Y /
t"EMn1uRiUM
Ouakor Road, Qu##nlbury# New York 12804
Phone (518) CremAtoriuAl 745-4477 or if no answer
Cemetery 745-4476
nUMO"1 ZnttuN to CREHntE
The uhdersigned request 's and AUthorizos Pine View Crematorium, in
accordAmco with and sub,j@ct tN itt Rul*t And Regulations to
cremate the rOMAins of!
Walton R . Mosher Male
(Nam@) (S@k)
17 Fawn- Rd Gansevoort NY 12831
(Street ) (City) (State) (Zip Code)
who died on 16 day of September 19 96
at Glens Falls hospital
(Place) (Addre+a! )
Name and addrlst of hOar@gt living rtlativ* or nand of person
Authbri= ing cremAtibh !
Mrs . Jessie Mosher 17 Fawn Rd . , Gansevoort , NY 12831
MAW (Addy-@40
Relatiohthip to tho deteaeed wife
Name bf f'UnerAl F(oml Carleton Funeral Home , Inc .
I MPbnt FIN(;
I aws ti to the blot of my (lnowlbdgl, the deceased has or,
b patew+akpt- hig bt- hot- bbdy: (Circle One)
1 certify that 1 have thb full power and author OAtion to arrange
for the crtmgtibo of the reriiain+! and to direct tho disposition of
the cr@Mated v-o*Aihs; thAt Ahy W—tbfiAl pb4W64% ions have either
boon realovod or may b@ d@ktrbyldi And agr@e to prot*ct , defe"'i
and 4av@ harmless Pine View Cr*Adtorium front any and all claims
and domand3 for loss or damagol which may be made Against them by
reAson of or cbhn@ct@d with th! t"O'"on of said remains as
d c d, whether sllch t1d1164 bl^ dfmhnd+a are or are not wholly
round l 4 Olst, or rr • udullnt .
Carleton Funeral Home , Inc .
tWitnp4s) (nddrets)
c
Gansevoort , -NY
(Signature of Relativ@ br LlgAl Rpp. and Address)
Signed on this date ! /�� �
bISPUS1tlUN OF CREMAtED RrmritNs
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[C 1 ES, C1UL�S AND [IEGUTA r[UNs
1. The crematorium wilt be open for cremations S days a wePi(
7 :00 A. M. - 3: 30 P. M. Monday-Friday. No Vial idays or 5un(iay-• ,
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 pint,
View Cemeteryi Uua►(er Roadi Town of Oueensbury.
3. An authorization For cremation properly signed by the neareet
nekt of kin or other authorized person stating that they do ha•:-
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 Pit—
View Crematorium tram any and Ali claims and demands for loss nr
damages which may be made AgAir;st them by reason of or connp,7 nri
with the cremation of sAid remains and/or disposition of ;atfi
remains as directed, whether such claims or demands are, or, art,
not wholly groundless, false or Fraudulent. This author iz�� i
in addition to a regular burial permit must accompany the
remains.
4. All r@miins must be encased in a casket or 'suitable alternate
container. CAsltets and containers must be of combustible
material. No styrafoam or plastic containers will be accepted.
5. Thr question relative to t4rdiac pacemakers must be anc%i-
on the authorization to cremAtO form before " the remain4 will t•r
accepted.
6. Unless other- arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within three days of crematior,
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 t175. 00
Children (age 13 months to 12 years ) t1O0. 00 Infants ( stillborn
to 12 months ) 460. 00