Moffatt, Edward 2�0W 7� OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-A., C�
Name _k DLj 9 ) Ji►urE/� / Case ii )V / 61
Date of Cremation
Time Cremation Started /�� z41641
Time Cremation Com'pl et eci r r M
Type of Container -11RDC/}9D 1,5 71, ��� ' � _� �
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phon (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersig ed requests and authorizes Pine View Crematorium , in
accordance ith and subject to its Rules and Regulations to
cremate the emains• of:
Edward Moffatt Male
(Name) (Sex)
One Main St. , Warrensburg, NY 12885
(Street (City) (State) ( Zip Code )
who died on 30th day of Nov. q 96
at GFH, Glens Falls, NY
(Place) (Address)
Name and add ess of nearest living relative or name of person
authorizing cremation :
Mrs. Shirley Moffatt, One Main St., Warrensburg, NY 12885
(Nave) (Address)
Relationship to the deceased Wife
Name of F u n e i al Home Adirondack Cremation Assn. , Warrensburg,NY
IMPORTANT:
I represent 1nat to the best of my knowledge, the deceased} {
has no pacemc ,cer in his or her body. (Circle One)
I certify thit I have the full power and authorization to arrange
for the creme tion of the remains and to direct the disposition of
the cremated remains, that any personal possessions have e : cner
been remove( or may be destroyed, and agree to protect , defenc
and save harrless Pine View Crematorium from any and all claims
and demands , or loss or damages which may be made against there by
re on lof oT connected with the cremation of said remains as
it to Of wtather such claims or demands are or are not wnoliy
rou 1 131se or fraudulent .
Warrensburg,NY
(Witnes - (Address)
X �
Same as above
(Sign u •e f Relative or Legal Rep. and Address)
Signed on th i , date : 12-1-96
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremate
remains as follows :
Mail 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 -4ee -
7 :00 A. M. - 3:30 P. M. Monday-Friday. No Holidays or Sunaays ,
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 alne
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the neares -
next of kin )r other authorized person stating that they do have
the power snd 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 �e
destroyed and agree to protect, defend and save harmless p : ^ e
View Crematorium from any and all claims and demands for loss o �damages which may be made against them by reason of or connecter
with the cremation of sai-d • remains and/or disposition of sa : c
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent . This author : zat : --
in addition to a regular burial permit
remains. must accompany - -.e
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combusticie
material . N styrafoam or plastic containers will be acceptea.
5• The question relative to cardiac pacemakers must be answe-ec
on the authorization to cremate form before the remains w : , ;
accepted.
6. Unless ether arrangements are made the cremated remains
be mailed vi . Registered U. S. Mail within three days of cremat : -_
to the funer�. l home handling the service. There s3 ,,
charge for tr. : s service. will be a
Cremation, Acministration Costs and Recording Fee : Adult
Children (age 13 months to 12 years) $ 100. 00 : lcc
to 12 months ) $60. 00 Infants cst :