Jacob, Marjorie rrng+N OF QUEEVBU-RY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
t
Funeral Director
Name ,�199-i-a = J/ czJ Case #i f D�
Date of Cremation 2'(�z
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Time Cremation Started /,S a-L
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Time Cremation Completed /e rM /7
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Type of Container
Remarks :
/176 &/F-p 19 .Al
P �� G �;3,3` /&
b I SPOS I r 1 UN OF cnEMrl T E[) Rr=Mm N4
I hereby direct Pine View Cremator-ium to dispose of the cremated
remains as Follows :
Mail to
Other arrangements - please specify :
If pulverization of cremate remains . is requested, check here
POLICIES, nULES AND REGl1LA r I ONS
1 . The crematorium will be open for cremations 5 days a wpplr
7 :00 A. M. - ; 3: 30 P. M. Monday-Friday. No Fto L i day s or Sunriaye ,
arrangements r_an bP made for Saturday. Pr-ear-rangements 1"
telephone for acceptance of remains is r►ecessary.
2. Pine View Crematorium is located nn the grounds of the Pino
View Cemeteryi Quaker Road, Towr► or Queensbury.
3. An authorization for cremation properly signed by the nears— t
next of kin or other authorized person stating that they do
the power and authority to arrange for the cremation of tlir•
remains and to direct the dispositior, of the cremated remains,
that any personal possessions have either been removed or may bp
destroyed and agree to protect , defend and save harmless Ciao,
View Crematorium from any and all claims and demands For lose - r
damages which may be made against them by reason of or conner•tnd
with the cremation of said remains and/or disposition of saiH
remains as directed, whether such claims or demands are, or ar-A
not wholly groundless, false or fraudulent . This auEhorizir- i ,—
in addition to a regul'ar burial permit must accompany 1:h"
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 ans►+r• rr,
on the authorization to cremate form before the remains will t,r•
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 ) t60. 00
TOWN OF UUEENSDURY
PINE VIEW CEMETERY
A
CIiEMA 1'UR I UM
uualter Road, Oueensbury, New York 12904
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
nul'I lull I znT 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 :
may c -Vpt 3o,co\0 r'e.nr C-a
(Name) (Sem)
(Street ) (City) (State) (Zip Code)
who died on - a day of MkNJ3rW- 1997
at cnlelo3 yna ks kos�1+01 106_Y`' AN.
(Place) 1nddress )
Name and address of nearest living relative or name of person
authorizing cremations
k.00e3t Q�acmh _ fi.fl-1
(Name) (Addroulm )
Relationship to the deceased 0 L;, )
Name of Funeral Home M. B . Kilmer Funeral Home
IMPORTANTs
1 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 proteet9 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
groundless, false or fraudulent.
(f aenLLL �<- �� 61 .o ya
(Witness) (Ad rasa )
� .2&nd-a-4:E AA L
(Signature of R tive or LeVal Re . and Address)
Signed on this dates � 19911