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Reynolds, Victoria ToTVN OF QUEEN,5BUXY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director E X ,A nl o FR 134ke Name V/ c—T© K 1 Q A. RIONOU5 Case # Date of Cremation Z Time Cremation Started + � Time Cremation Completed Type of Container �> c") Remarks : 4116 1l 11 C�) DISPOSITION OF CREMATED REMAINS I hereby d sect Pine View Crematorium to dispose of the c--emate,, remains as ollows : Mail to Other arrangements - please specify : If pulveriz, : ion of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1 . The crEaatorium will be open for cremations S days a wee 7 : 00 A. M. - 3: 30 P. M. Monday-Friday. arrangements can be made for Saturday. Ho Prearranlidaysogement , s , telephone fc - acceptance of remains is necessary. 2. Pine VIE Crematorium is located on the grounds of the pine View Cemeter , Quaker Road, Town of Queensbury. 3. An authc -lzation for cremation properly signed by the nearest next of kin r other authorized person stating that they ao ha, e the power nd authority to arrange for the cremation or -,- e remains anc to direct the disposition of the cremated remains , that any Pe sonal possessions have either been removed or may :e destroyed a d agree to protect , defend and save harmless pane View Crematc ium from any and all claims and demands for loss o damages whit may be made against them by reason of or connectec with the cr mation of said remains and/or disposition of sa : c remains as c rected, whether such claims or demands are, or are not wholly soundless, false or fraudulent . This author : zat : --_ in addition to a regular burial permit remains. must accompany t e 4. All rema ns must be encased in a casket or suitable alternate container. Caskets and containers must be of material . N styrafoam or plastic containers will be acceptea. • e 5. The que tion relative to cardiac pacemakers must be answe--e on the autho ization to cremate form before the remains ll accepted. b• Unless :her arrangements are made the cremated remains be mailed vi , Registered U. S. Mail within three days of eremat to the funer, home handling the service. There will be a s3 : charge for tr s service. Cremation, Ac linistration Costs and Recording Fee : Adult $ -5, "� Children cag � 13 months to 12 years) $ 100. 00 co. 70 12 months ) $60. 00 Infants Est : : l TOWN OF DUEENSBURY PINE VIEW CEMETERY i 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: 0c,lbRa4 A. 2EUlvot- �c� m9c (N. me ) (Sex) r-"nc-.nd 11Au.Eu 24. $�{i 1<cJan/ AJI-4 / (Street ) (City ) (State) ( Zip Code ) who died on 30 day of 51N. l9 QZ_ at tOX4 Al c C1,644'AN I't&PI-M L-I C /3!1 rDC7E (Place) (Address) Name and address of nearest living relative or nave of perscn authorizing c^emation : C LW a4NCC-- .SDI: SSLgw— are( , C/wo ,91,t'W AO , SN OX14'W f Nq 12g"73 (Nave) (Address) Relationship :o the deceased- Q4U614-7£2 N am e of F u n e r 31 Home AA'2av0*.W Q?44!q,;rQ„/ A rSoG R 7 S In�9 22c-�y,(�c12�� ye,� IMPORTANT: I represent teat to the best of my knowledge, the deceased r has no pacema <er in his or her body. (Circle One ) I certify tha : I have the full power and authorization 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 , defenc and save harm '. ess Pine View Crematorium from any and all claims and demands f )r loss or damages which may be made against them by reason of or connected with the cremation of said remains as directEnv her such claims or demands are or are not wnoliy gro dse or fraudulent . warn&ma mG 0 n.- ( � (Address) (Signature of Relative or Legal Rep. and Address ) Signed on th i , date .