Jackson, Roger tt]iJN C1E bWtNSgUttY
P I NE V ION t.EME 1 E!t Y
t nr-HntunIUM
Quaker Road, UuoOnSbUry, NOW York 12804
Phone (518) CrematoriuA 745-4477 or if no answer
Cemetery 745-4476
nUMuni Znt1UN to emmnm
The uhdersignod request 's and authorites Pine View Crematorium, in
accordAhce with and sub,joct tti itt Ru1t4 And Regulations to
cremate the rO*Ains of :
Roger Raymond Jackson male _
(Name) (Serf)
15 Beec.h Street Hudson Falls NY 12839
(Street ) (City) (State) (Zip Code )
who died on loth day of September 1996
at 15 Beech Street , Hudson falls , NY
(Place) (Addrtos)
Name and addrl93 of heareot living relative or nAmt of person
Authbrizing cremAtibn!
_Mrs Ramona Jackson 68 Feeder st . , Hudson Falls , NY
(Na(ne) (Addreoo)
RpllAtiohthip to the detogtod mother
Name bf 1•Uheral Nome Carleton Funeral Home , Inc .
i Matlnt t1Nt!
-- rbpr t to the blot of My Nhowledge, the deceased has or
hao t1b pa►tlaak0 ih hie br her bbdya (circle ono)
1 ter i y at 1 ha+,o th* full pow#t- And authorization to arrange
for the crOmAtion of the toosint and to dirtct tht disposition of
tht ct-omated t-tMAihsy that AhV 136h3bhAl pbesb+toions have+ either
both reAoved br may be de§trbyodi and agree to protect , defe►iri
and §ave harmless Pine View Cro#AtoriUm from any and all claims
and demand* for loss or dAmag#4 which may be made Against them by
reAoon of or connfeted with tht thtmAtibn of Maid remains as
dire ed, whether such tlaifio br d#Mhnd4 Art or Are not wholly
gr n ll�S�§, sp or rAudUlt+nt:
" 'I Carleton Funeral Home Inc .
Wi npos) (Rddre+ts)
Hudson Falls , NY
(Signature 4 Relative or Legal Rep. and Address)
Signed on thi3 dates `" ���,��
I)ISPUSItIUN OF C"r=HntEt) tir--MntNS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows .
Mai 1 to
Other arrangements - please specify : ___ ___
If pulverization of cremate remains is requested, check here
POLICIES, f1ULES ANU "EGULAtIUNS
1 . The crematorium will be open for cremattons 5 days a wo 01(
7.00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or 5unday'% ,
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 pine
View Cemetery; Quaker Rdadi Town of Oueensbury.
3. An authorization for cremation properly signed by the nearest
next or kin or other authorized person stating that they do ha p
the power and authority to arrange for the cremation of t,tr
remains and to direct Cho disposition or the cremated remains,
that any personal possessions have either been removed or may be
destroyed and agree to protect, defend and save harmless pirrp
View Crematorium from any and all claims and demands for loss nr
damages which may be made against them by reason of or connertpri
with the cremation of said remains and/or disposition of sat•l
r@mains As directed, whether such claims or demands are, or arm
not wholly groundlessi false or fraudulent. This authorizAt- r ,,
in addition to a regular burial permit must accompany t11'?
remains.
4. All remains must by encased in a casket or suitable alternate
Container. CASIAPts and tontainers most be of combustible
material. No styrafoom or plastit containers will be accepted.
5. The question relative to Cardiac paceMakers must be ansr+p,
on Cho authorization to cremate form before the remains 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 $20. 00
Charge for Chi s set-vice.
Cremation, Administration Costs and Recut-ding Fee ! Adult W 5. 00
Children (age 13 months to 12 years ) 4100. 00 Infants ( stillbor-n
to 12 months ) 460. 00