Glickman, Erica TOWN OF bl1EENSBURY 13
PINE VIEW CEMETERY
4
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned request 's and authorizes Pine View Crematorium, in
accordance with and subject td its Rules and Regulations to
cremate the remains of:
Erica C. Glickman female
(Name) (Sex)
49 Lafayette Street. , Hudson falls, NY 12 qq
(Street ) (City) (State) (Zip Code)
who died on 18th day of October 1996
At Saratoga Hospital Nursing Home, Saratoga Springs, NY
(Place) (Addrlst)
Name and addrlss of nearest living relative or name of person
authorizing cremation:
_ Mrs Teresa Scarselletta 49 Lafayette St. , Hudson Falls, NY 1?Rqq
(Name) (Address)
Relationship to the deceas*loth r —
Nam* of Kuneral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of icy knowledge, the deceased has or,
has no pacemaker in his or her body. (Circle One)
I certify that I havt the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated relnaihs, thAt ahy p0-40hal pos+tlssions have either
been removed or may by dettroypdo and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with tho cremation of said remains as
directed, whether such claiM4 or dtoands are or are not wholly
groUnd4tgtt al a fraudulent.
Carleton Funeral Home Inc.
(Witness) (Address)
4Q _ Hudson falls, NY
(Signature of Relative or L&galgqRep. and Address)
Signed on thit date : c1L% ��� ZT/,
DISPOSITION OF CREMATED RF:Mn1NS
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
POLICIES, "ULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week
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 Pine
View Cemetery; Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do ha,.,A
the power and authority to arrange for the cremation of thr,
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 Pine
View Crematorium from any and all claims and demands for loss of
damages which may be made against them by reason of or connect-r+
with the cremation of said remains and/or disposition of satri
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This authorizz - i ,
in addition to a regular burial permit must accompany the
remains.
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible
material. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be anst+P, r ,(
on the authorization to cremate form before the remains will he
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 $20. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult $ 175. 00
Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn
to 12 months ) t60. 00