Hicks, Franklin a
TO%N OF QUEEVBU-fkY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorGY /1!
Name// !�!t/� /�G�� Case It
Date of Cremation ���7 / 7
Time Cremation Started /IX d-,M `
Time Cremation Completed •i,5_3 A /l�',�
Type of Container �',� - / �� ��d
Remarks :
i� �� ta7r4�� �
TOWN OF OUEENSDURY
PINE VIEW CEMETERY Z2 /
a
CREMATORIUM
Quaker Road, Oueensbury, New York 12804
Phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CRE14ATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
t K
(Name) (Sex)
i
6 I PI/Mal f-�ru-�y �,e, �F � � y Ny /L ��
(Street ) 2 - (C i t/y ) (State) ( Zip Code )
who died on 3 day of
at
(Place) (Address)
Naime: and . address of nearest living relative or name of person
authorizing cremation :
UAL M /3 r� L6 to
„ (Name.) (Address )
�
Rehationship .to the deceased A/!`I�V(7lr/✓��� ___.
Nance o{f Funeral Home �f�
IMPORTANT:
sent that 'to the best of my knowledge, the deceased has or
has n pacemaker in his or her body. (Circle One)
I cert'i7fy'' that I have the full power and authorization to arrange
for• the' cremati'on of the remains and to direct the disposition of
the' cremated `x remains, that any personal possessions have either
been removed or may be , destroyed, and agree to protect, defend
nd)'s'ave harm'l'ess Pine View Crematorium from any and all claims
" and t 'demand's`for' loss or damages which may be made against them by
reason of or connected with the cremat.-ian of said remains as
directed, whether such claims or demands are or are not wholly
groundless';'''faIs'e" or fraudulent.
(Witness ) (Address )
Lurk
(Signature of ReiatAive or Legal Rep. and Address)
Signed on this date : —1 ! �
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 Flo 1idays 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 perm
addition to a regular burial it must accompany the
remains.
ti• , All remains must be encased in , a
container. casket or suitable alternate
Caskets and containers must be of cumbustible
" �n • � �
aterial .` y No st r�zfoam or 3 plastic_ containers will be accepted.
s•" " The question relative to card ac pacemakerson t must be answered
accepted. h'orization to cremate form before the remains will be
accept ed, :,;�_�.:.•;
' Unless other arrangements are made the cremated be mailed -via Registered U. S. remains will
to the Mail ithin three days of cremation
funeral home w handling the service. Ther
charge--for- this service. e will be a t20, 00
Cremation, Administration Costs and Recording Fee : -Adult $ 105. 00
Chi_le.n_,v.,,(age.. 13 months to 12 years ) s17.0. 00 Infants ( stillborn
to 12- month's )t% s j0. 00