VanVleet, Donald TOWN OF QUEENS 21-'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director LC'.d (
Name 14d, P&,,c- Case # C/r►7
Date of Crematicn
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
AM I N ,C301?X09-9
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TOWN OF UUEEN58UftY
PINE VIEW CEMETERY
CREMATORIUM
Qudker Road, Oueen;bury, New 'cork 12804
Phone (518) Crematorium 745^-4477 or if no answer
Cemetery 743--4476
AUTHOR I ZRT I ON TO CRE-MATE
The undersigned requests and authorizes Mine View Crematorium, in
to its Rules and Regulations to
accordance with and subject
cremate the remains of
(Name) (SeK)
w1ro Lt ) rJ
r � �
(Street ) aL City) (State) Zip Code ) ']
who died on 0 a, day of
at c Ka �{.C'�Y1 - C� 1 -
( lace) (A dress)
Name and address of nearest living relative or name of person
authorizing cremation:
Ltta
jh,�,q,r
(Name) (Address)
r
Relationship to the deceased
Name of Funeral Home 1-1j,lea
IMPORTANT:
I re resont that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. Wircle 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 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 or damages which m,Ay be made against them by
reason of or connected with the cremation of said remains a
directed, whether such claims or demands are or are not who'
groundless, fal e o fraudulent.
(Witness)
(Signature of Relative or LegalJRop. and Addre
7ned on this dates �'�
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
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 week 7 :00
A.M. - 3 : 30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
2 . Pine View Crematorium is located on the grounds of the Pine
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 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 regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
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 $195 . 00
Children (age 13 months to 12 years ) $115 .00 Infants ( stillborn to
12 months) $75 . 00
* Additional $50 . 00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .