Morehouse, Doris TOWN OF OUEENSBURY
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 requests and authorizes Pine View Crematorium, in
accordance with and subject ' to its Rules and Regulations to
cremate the remains of:
Doris Ilean florehouse Female
(Name) (Sex)
Weatmount Health Facility Queensbury, NY 12804
(Street ) (City) (State) (Zip Code)
who died on 25th day of December 19�96
at_Weatmount Health Care FaciiityGurney Lane Queensbury NY 12804
(Place) (Address)
Name and address of nearest riving relative or name of person
authorizing cremation:
Teri Viggiano 29 'Rhode Island Ave.
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Carleton Funeral Home Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
hat no pacemaker in his or her body. (Circle One)
I certify that I have the fullpower and authorization to arrange
for, the cremation of the remains and to direct the disposition of
thy► cremated remains, that ar.y personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and al .. claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
direc , whether such claims or demands are or are not wholly
grou dl s, alse or fraudulent.
(Witness) (Address)
/
7w� �V
(Signature' Relative or Legal Rep. and Address)
Signed on this date : � ��� L/ � �O
DISPOSITION OF CREMATED REMAINS
hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
�',a i l to
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
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. Prearranga: ments by
telephone for acceptance of remains is necessary.
P— Pine View Crematorium i ,-. located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
r,W�;t 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 connected
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 regula- burial permit must accompany the
remains.
4. All remains must be encased in a casket or suitable :Aternate
container. Caskets and containers must be of cot. justible
mz.terial. No styrafoam or plastic containers will be ar.-cepted.
5. The question relative ti cardiac pacemakers must be answered
o', 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