Kravel, Tina TOWN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
t
Funeral Director _ /(//IM
Name 111Nyd \ ,� Case #�
Date of Crematicn L ;z�— I t
Time Cremation Started at(0 oZ lit"
r -
Time Cremation Completed< 1;./s— fM
Type of Container �7�oi4R]J ?�� Cr�Sh� 4FTiS< �J �/
Remarks :
�� lI //r, 4Cri91M
I� �l " �a ►� el f A '
UISPUStrtUN OF CREMn1Eq RrmntNS
I hereby direct pine View Crematorium to dispose of tt,e cremated
remains as follows :
Mail to
Other arrangements - please speciFy : _ _
If pulverization of cremate remains is requested, check here
POLICIES, RULES nNU REGl1Ln T i ONS
1. The crematorium will be open for- cremations 5 days a wpolr
7see n. M. - 3: 30 P. M. Monday--Friday. No 1101 idays or Sunrlay� ,
arrangements r_an ho made for Satlrr'day. Prearrangements ► ,
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located 0ri the grounds of the pino
View Cemetery+ Oual(er Road, Town of Oueensbury.
3. nn authorization for cremation properly signed by the nearoot
next of kin or other authorized person stating that they do h-1vp
the power and authority to arrange For the cremation of thf'
remains and to direct the dispositior, of the cremated remains,
that any personal possessions have either been removed or may be
destroyed and agree to protect, defend and save harmless Piro
View Crematorium from any and all claims and demands for 10s ; - r
damages which may be made against them by reason of or conner•t: 1
with the cremation of said remains and/or- disposition of ;arri
remains as directed, whether such claims or demands are, nY' .1Y'r
not wholly groundless, false or fraudulent. This authr)riz%t- i •••-
in addition to a regular burial permit must accompany tip
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.
S. The question relative to cardiac pacemakers must be ansr,r-1
an tho authorization to cremate form before the remains will t,v
accept ed.
6. Unless other- arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremetinr.
to the funeral home handling the service. There will be a $20. 00
Charge for this service.
Cremation, Administration Costs and Recording Fee : Adult 6175. 00
Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn
to 12 months ) t60. 00
TOWN OF (JOEENSDURY - T
PINE VIEW CEMETERY
A
U,REMR fUR I UM
Quaker Road, (]ueensbury, New York 1ea64
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
nuu mli I zm[UN TO CREMRTE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
�T111 A �Q2i �j + l 4
(Se")
1 Zs 3
(Street ) 2 (City) (State) (Zip Code) y
who died on 2'7 day of `l� lg /
at —rht (aka PICIAll A v,`J4' -1
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
t4w W" 4)W4'�+
(Name) (Addroa= )
Relationship to the deceased__JL��
Name of Funeral Home M. B . Kilmer Funeral Home
IMPORTANT2
I represent that to the best of my knowledge, the deceased has or
has no pacemaker 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 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 may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
oundless, false or fraudulent.
(W i-.ness ) (Address )
(Signature of Relative or ,gal Rep, and Address)
Signed on this date :