Smith, Robert o��� OFQUEEVBU9?'Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case !!
Date of Cremation ' — ` /
Time Cremation Started / � ® /4 ' I�1
Time Cremation Completed 'T2o A , m
Type of Container C /a (2cq O!ar 1 57 C/45,' O.4' T h e Q 9
Remarks :
1l 11
1/ 11
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 . ee -
7 :00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or 5uncays ,
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 :) Ine
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 coo tim e
the power and authority to arrange for the cremation of the remains and to direct the disposition or the cremated remains ,
that any personal possessions have either been removed or may ze
destroyed and agree to protect , defend and save harmless pine
View Crematorium from any and all claims and demands for ! oss o �
damages which may be made against them by reason of or connectec
with the cremation of said remains and/or disposition of sa : c
remains as directed, whether such claims or demands are, pr are
not wholly groundless, false or fraudulent . This author ; zac .' :_
in addition to a regular burial permit remains. h must accompany the
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combust : c : c
material . No styrafoam or plastic containers will be acceptee.
5. The question relative to cardiac pacemakers must be answe-ez
on the authorization to cremate form before the remains w : : ! _e
accepted.
6• Unless other arrangements are made the cremated remains
be mailed via Registered U. S. Mail within three days of cremat :
to the funeral home handling the service. There will be a
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult Children (age 13 months to 12 years) s100. 0O Infants
to 12 months ) $60. 00
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
i
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phon( (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigred requests and authorizes Pine View Crematorium , in
accordance vith and subject to its Rules and Regulations to
cremate the remains' of;
Robert D. Smith Male
(Name) (Sex)
Horicon Ave. , Box 8, Warrensburg, N.Y. 12885
(Street ) (City) (State) ( Zip Code )
who died on 29 Th day of Jan. 19 97
at Glens Falls Hospital, Park St. , glens Falls, N.Y. 12801
(Place) (Address)
Name and address of nearest living relative or nave of per-scr
authorizing cremation :
Mrs. Martha C. Smith, Horicon Ave. , Box 8, Warrensburg, N.Y. 12885
(Name) (Address)
Relationship �,o the deceased Wife
N a m e o f F u n e r a l H o m e Alexander-Baker Funeral Home
IMPORTANT:
I represent tnat to the best of my knowledge, the deceased XXM=
has no pacema,�er in his or her body. (Circle One )
I certify that 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 e : tner
been removed or may be destroyed, and agree to protect , defend
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
directed, wh ?ther such claims or demands are or are not wnoliy
404�__HCR-1,
;lse or fraudulent .
Box 23-B2, Chestertown, N.Y. 12817
(Address)
(Signatu a of Relative or Legal Rep. and Address)
Signet on thi date :