Wiley, Marjorie tow tw dUEENSNURY
PINE VIEW CEMEttAY 4 �/J�
CREMATORIUM 07
Quaker Roads Quo0h4buryt Now York 12804
Phone (51a) Cr#A&toriuM 145-4471 or if no answer
CeMet*Py 145=4476
AUTHOR I t(it I ON tt1 CREMATE
the undersigned request% and Authorize! Pine View Crematorium, in
atcordance with Ahd 3ub,j#ct to its !lulls and Regulations to
creMAti the riMains off
Marjorie Ellen Wiley Female
tNam�r) (Sex)
38 King Ave. Hudson Falls, NY 12839
(Street) (City) (state) (Zip Code)
wH6 d i#d 6h 25t 96
h day o f October 1�
at Glens Falls Hospital 100 Park Street Glens Falls, NY 12801
tPlaci) (AddroW
N&Me afid Addi-fit of n#Ar#(!t 1iviNO r#latiV# br nAm# of person
iiUtH6r" i�iiij cf^(tMAtiiin:
Mr. Bruce F. Wiley 38 King Ave.
tNAM#) (Addrfli)
kolAtiefishio t$ that d#eoA%#d Husband
NM M ar [)# a=ufi e r M 1 H # Teton Funeral Home Inc.
I WOOtANT e
,,.
l a^i watsint that to th# bitt tlf My khbwlodge, the d#ee436d has or
+! fi pat:la Skei^ in hit or Hoi^ body: (Circle One
i:ePtify that f hAv# the full Oawot; And Authorization to av,rango
f6r the ctAom&tion of the riMAihs and to direct the disposition of
tho C-IA#Aatald f`eMAifi9# that AhV 0s►r3ofiAl po63i44i6ns have either
been f-#46y#d 6r MAy 6@ dostt^dyid, afid &§r#O to protect, defend
and save hArM1693 Pih@ View Crematorium from any and all claims
and demands for loss or dAMAg#s which May be made against them by
f�i�►+1btl tl 6fz conh#cted with thi cf #MAtion of said remains as
diP'ectid# whither' Ouch claims o0 demands are or are not wholly
graiutidl f&it# orb fr'iudul#ht&
c tfiissi taaddre+i#)
J"'- 3, 1 v V�- �I vo
(Si nature of Relative or igal Reps and Address)
gighod Oh this dads
DISPOSITION OF CREMATED REMAINS
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 .sere
POLICIES, RULES 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 Sundays,
arrangements can be made for Saturday. Prearrangenents by
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 have
the power and authority to arrange for the cremation of the
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 ronnected
with the cremation of said remains and/or disposition of said
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This authorization
in addition to a regular burial permit must accom?any the
r vvains.
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 answered
on the authorization to cremate form before the remains will be
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) $60. 00