Schmitt, Charles TowN OF QUEENSBWZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director lJ 14CQx QZ?�AA'
Name #M ;T7— Case it
Date of Cremation /0
0
Time Cremation Started ! z 41m ,
Time Cremation Completedy e kI4 4 //Yct
Type of Container s/
Remarks :
Ai'eA1 N
14-16
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TOWN OF QUEENS®URY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION 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: / Male-
(Name)
(Sex)
96 22 Z,,- secl 0
(Street ) (City) (State) (Zi6 Code) Q�J
who died on �. day of s7co - 19�L
at 9099 �rax i a834,
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
V. r
(Name) (Address)
Relationship to the deceased
Name of Funeral Home Zzllt
IMPORTANT:
I re esent that to the best of my knowledge, the deceased has or
has 0c 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 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
grow less, false or fraudulent.
(lYitness) (Address)
G^'
(S. nnature of Rela iv� or Legal Rep. and Address)
ziSigned on this date : 7
I a>;CST;:QhR .1,7 CREMPTED REMAINS
? het-aby direct Pine View Crematorium to dispose of th? cremated
rv!iainy as follows :
Mail to
Other arrangements — please specify :
If pulverization of cremate remains is requested, check F.ere
POL a 3..;I FS, RULES AND REGULATIONS
Li—_matorium will be open for cremat .ons 5 days a week
z ori'vaY-. r id.'.".. iNo HulY. ay-., co Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary.
R. Pine View Crematorium is located on the grounds of the Pine
view Cemetery, Quaker Road, Town of Queensbury.
3. An authori. zation for ._remation properly signed by the nearest
r;e>,t of Erin ;v cther authorized person stating that %hey do have
:"he power and authority to arrange for, the cremation of the
i emains and to direct the disposition of the c,^err, ted remains,
tr,i7at: :gin•; personal possessions have Either been remo: ed,' or may be
destr-�yed and agree to protect, defend and save harmless Pine
Yiew Crematorium from an, and all claims and demands for loss of
damag-as which isay be mace against them by reason of or connected
with the= cremation of said remains ar.d/or disposition of said
r-,mains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This :tfaurization
i -I o.dditi -n to .. rcr_.iular burial permit must a-(--u,apany the
remains.
4. All remains must be encased in a casket or suitable alternate
container- Ca.s6:et = anti cnntainers rust he of combustible
material. No styrafoam or plastic containers :v; ll be accepted.
5. Ti;c question relative to cardiac pacemake•,s must be answered
on th? authorization to cremate form before the remains will be
accepted.
6. Un). es-; other arrangements are made the crematc.•d re,,; a,ins wi 11
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 o185. 00
Children (age 13 months to 12 years) $ 110. 00 Infants ( stillborn
to 12 months) '$70. 00