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Dickinson, Larry (Leg only)
TOWN OF QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Cod /1Z'6� /U/Y t Name J— // fC'./1 i�/� /V �f ©4 ase # Date of Crematien_ 'd Time Cremation Started 7143c� / M Time Cremation Completed /! Type of Container /f t7,5:�l /!!57 / Cjj�CIL�' T-,f- f� Remarks : A 1 Ai N .C3lJ".'e-g off , ,� 11 // I I i I i I i bISPNSittUN OF CREmnmu Rr-MnIN5 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, t1ULt=S nNU REGULA r i UNS 1 . The crematorium will be open for cremations S days a 7 :00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or Sunday, arrangements can be made For Saturday. Prearrangements t', telephone For acceptance of remains is necessary. 2. Pine VieW Crematorium is located on the grounds of the Pino View Cemetery; Quaker Roadr Town of Oueensbury. 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 rrf tt,r 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 Pit," View Crematorium from any and all claims and demands For loss of damages which may be made against them by reason of or connect "'t With the cremation of said remains and/or disposition of swirl remains as directed, whether such claims or demands are, or ar-r not wholly groundless+ false or fraudulent. This authorizat- i -- in addition to a regular bUrial permit must accompany tllr? remains. 4. All remAin4 must by oncased in a casket or suitable alternate tontainor. C451Aets and tontainers must be of combustible material. No styrafoam or plastic containers will be accepted. 5. Th# question relative to tardiac pacemakers must be anr.%j . on thb authorization to cromgtp form before the remains will t � accepted. I 6. Unless other- arrangomontt are made the cremated remains will be mailed via Registered U. S. Mail within throe days of cremation to the, funeral home handling the service. There will be a t20. 00 Charge for this service. I Cremation, Administration Costs and Recording Fee : Adult 4175. 12W j Children (age 13 months to 12 years ) t100. 00 Infants ( stillborn ) to 12 months ) f60. 00 • I i bNN of bU1=�NstlUtty (SINE V11=N t:EMEtEttY � �� Ct1�Mq?UR I UM Quaker Road, UuoOntbury, New York 12804 Phone (518) CrematoriuO 745-4477 or if no answtr Cemetery 745-4476 AUtt onizntfuN ttl CREMATE The undersigned request 's and Authoritts Pine View Crematorium, in accordAnce with and sub,jOct td it * Rules And Regulations to cremate the remains of: Larry Dickinson (LEG ONLY) (Nam!) (S@0 39 Fourth St . , , Glens Falls NY 12801 (Street ) (City) (Stato) ( Zip Code ) who died on NA day of Nn 19 at NA (Pl6ce) (Addrl93) Name and addrEss of nearest living relative or "Ante of person Authbri21hg crematibh ! Larry Dickinson (NAMOP) (Addre s,) Relatiohthip to thb deteased self Name of t-unerall Nome Carleton Funeral Home , Inc IMPbR1ANTi t represent that to tht best of My knowledge, the decea►std has or has hb pat@*Aker ih hit bl- her bbdy: (Circle one) 1 Certify that l hav* th* full poWlr And Atuthori2ation to arrange for the cremation of the rOOMI n3 And to dirtct the disposition of thr ct-#NAlt#d V-tMAihsi thAt ahy 136r3bhgl possessions have either both reAovbd or may be dokt►-bytdj And agree to protbct , defetiH and save harmless Pine VieW CroAtatorium from any and all claims and demand3 for loss or d6odge* which may be made Against them by r@94on of or coh"@cted with the trOmAtion of *aid remains as trotted, whether 'such L-lai4s or demhnd+i are or art not wholly oundleSt Tt !lst or frAUdulentc ( 68 Main st , Hudson Falls , Ny 12839 (Witness) t (nddrets) 39 Fourth St , Glens Falls , NY 1280 (Signature of Relative or Legal Rep. and Pddress) Signed on that date : 9/18/96