Stevens, Abbie rIO UN OF QUEEVBU-Ry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ — 1< 1 ( �%
Nameh� i STe-f-e Case # 3�'�
Date of Cremat i cn — I S `9 /
Time Cremation Started 1l �� (0, A ' m
Time Cremation Completed 9,Q 0 - mf
Type of Container e e-rd B(�0._p"a c sT c NSA ac7` Thy
Remarks :
1� 11
TOWN OF t]IIEENSbURY ��s�
DINE VIEW CEMETERY
A
CREMnrURIUM
Quaker, hood, UtAeensbury, New York 12a04
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
nuT11OR I Zr1T I ON TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
Female
(Name) (Seat)
39 John St. , Greenwich NY 12834
(Street ) (City) (State) (Zip Code)
who died on 12th day of September 19 97
at Pleasant Valley Infirmary, Argyle, NY
(Place) (fldtlress )
Name and address of nearest living relative or name of person
authorizing cremation :
Jeffrey Wilbur 39 John St. , Greenwich, NY 12839
(Name) (Addrea= l
Relationship to the deceased grandson
Name of Funeral Home
M. B . Kilmer Funeral Home
IMPORTANT3
I represent that to the best of my knowledge, the deceased has or
has no pacemaker irr 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
groundl s, false or` f udulent.
(W Uil ri s) (Address )
(S re of Relative or /legal Rep. and Address)
Signed onC'is dates I3
UISPOSI uN OF CREMATED nrmnINS
I hereby direct Pine View Cremator- ( ram to dispose of tt,e cremated
remains as follows :
Mail to
Other arrangements - please
If pulverization of cremate remains is requested, check here
POLICIES, "ALES nNU RE GULA i I[1NS
1. The crematorium will be open for cremations S days a wooer
7 :00 A. M. - 3: .30 P. M. Monday-Friday. No Holidays or Sunday- ,
arrangements cAii bP made for, Ssturday. Prearrangements ► ,
telephone for acceptar►r_e of remain% is riecP%gary.
2. Pine View Crematorium is located on the grounds of the Pino
View Cemetery+ Quaker Road, Towr► of Uueensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do ha,:r,
the power and authority to arrange for the cremation of tFI"
remains and to direct Elie disposition of Elie cremated remains,
that any personal possessions have either been removed or may bp
destroyed and agree to protect , defend and save harmless Pino
View Crematorium from any and all clams and demands for los , nr
damages which may be made against them by reason of or convert —1
with the cremation of said remains and/or' disposition of qa ►ri
remains as directed, whether such claims or demands are, pr -1rr
not wholly groundless, false or fraudulent. This authorizir- i —,
in addition to a regular burial permit must accompany th"
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 ansr,cr -
on the authorization to cremate form before the remains will t,
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 $ 175. 00
Children (age 13 months to 12 years ) t100. 00 Infants ( stillborn
to 12 months ) 160. 00