Pollman, Bertha T- O- q+N OF QUEEVBU-' �y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director :5/ / ✓4 tU(, P ,,
Name
Date of Cremation
Time Cremation Started
Time Cremation Completed &4 t.S ! ?A �
Type of Container �� tJ /(� glif'ol
Remarks :
r
l� lI 14 dim ,
011
TOW br ol1EENSBURY
pINE VIEW EEMETERV
CREMATORIUM
Quaker Road, uueensbury, New York 12904
Phone (518) Crematorium 745-44775or if no answer
Cemetet-y
AUtHU"I tilt tUN TO CREMATE
in
The undersigned requests and authorizes
SRPineules Viewand Regulations to
accordance with and subject
cremate the remains of:
(Sex)
(Name) 12-86
(Street )
(City) (State) (Zip Code)
who died on day of 19-11
at (Place) (Address)
living relative or naMO of person
Name and address of nearest
authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPURTF1NT: knowledge, the decoAsed has or
ent that to the best of my (Circle dne)
ras no acemaker in his or her body.
I certify that 1 have the full 'power and authoi^iiatibn to arrange
ion of
for the cremation of the that
personal to dipossessions rect the shave teither
the cremated remains�et���estroyed, arid agree to protect, defend
been removed or may
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 ore hen" uchdclaims or with e demandsoareoorsaare not wholly
directed, wh
gro les , f r fraudulent.
(Witnes (Rddress)
�p t Aly
� � f
(Signature of Relative or egal Rep. and Addre s)
Signed on this date : ��
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
cunt-a! roer-. Caskets and containers or,utit 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 $185. 00
Children (age 13 months to 12 years ) f11:0. 00 Infants ( stillborn
to 12 months) $y0. 00