Webster, Gene T01P,N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director VP'?1" `-10 (A
Name 6 WE w GL.l '5t ase #
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container (zr3, Cea-TKeA? , 2 e.
Remarks; /-Dc} Lj
kj
tbiJN t>K bUt=�NStlUFIv
PINE vitw CEMEtE"y
a
ChEMntURIUM
Quaker Road, Uuetntbury, New York 12804
Phone (518) CremAtorioA 745-4477 or if no answer
Cemetery 745-4476
nUMu"I2httUN tb CREMnTE
The uhdersigned request 's and authoriies Pine View Crematorium, in
accordAhco with And sub,j@ct td Ito Rules And Regulations to
cremate the remAins of=
G6ne Fd1r 1 J : 4 t
(Name) (SerF)
S Code )
(Street ) (City) (St At P
who died on $ day of 19—
at Glens Falls Hos
(Place) (Addrle@ )
Name and addre43 of hearest living rrlAtivo or "AM* Of person
Authbr-i t i hg cremAt i bh
Mrs. Betty
(Na1ne) (Addr@§0
Rolatioh§hip to the doteased Wife
NAIM# of Punerdl Nomb Carleton
1 MPOnI nNT e
l represent that to the beet of my knowledge, the deceased has or
i� Pat**skor ih hie bh heh bbdya (Circle Une)
(al—t—errtt i fy that l hgvo th* ful l pnwrr and outhort zat i on to arrange
for the crOmAtion of the reMain3 and to direct the disposition of
the creMated rtMAihs; that any per'96hal pot4f4gions havo either
both reAovtld o.r May be destrbyedi And agree to protect , defer,ri
and §ave harmless Pine View CrtMAtorium from any And All claims
and demand§ for loss or dAmAgej which may be made Against them by
roAson of or cohn@cted with the tremstion of laid remains as
directed, whether such t1Ai44 br d6m6ndt are or art not wholly
groUndltS§, Pals r frAudolf+nt:
(Witne§s) t ddre9s)
(Signature of Relative or Llgal Rop. and Addre§s)
Signed on this date :
bISPUSItIUN OF CnEmn l) Rr--MnINs
I hereby direct Pine View Crematorium to dispose of tt,e cremated
remains as follows .
Mail to
Other arrangements - please specify :��U ACAlf y1 11111 (. �p�C� 1.1
If pulverization of cremate remains is requested, check here
PUL I C I ES, nuL1=5 nNU "E(;ULA t I UNS
1. The crematorium will be open for cremations S days a wppi<
7 :00 A. M. - 3:30 P. M. Monday-Friday. No tloltdays or Sunday..
arrangements can be made for Saturday. Prearrangements t"
telephone For acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pinp
View Cemetery; Ouaker Roadj Town of Oueensbury.
3. An authorization for cremation properly signed by the nearest
nomb of kin or other authorized person stating that they do havp
the power and authority to arrange for the cremation of 1:hr•
remain% 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 Pinp
View Crematorium From any and all claims and demands for loss „ r
,damages which may be made against them by reason of or conner-ter+
With the cremation of said remains and/or disposition of s.alrl
remains as directed, whether such claims or demands are, or ar,C,
not wholly groundless# false or fraudulent. This authorizO- t •,,
in addition to a regular burial permit must accompany thrz
remains.
4. All remalins mutt b@ encased in in casket or suitable alternate
container. Caskets and containert must be of combustible
Material. No %tyrafoam or plastic containers will be accepted.
S. The► question relative of cardiac pacegrakers must be ansto—
on thr authorization to creMAtO form before the remain% will hr
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 420. 00
charge for this service.
Cremation, Administration Costs and Recut-ding Fee : Adult I175. 00
Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn
to 12 months ) t60. 00