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Mercier, Pauline TORN OF QUEEVBU-RY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director /X�/k /mAz-20 Name T/- lJ�l}l�� l+'l��l�C/l Case # �7b Date of Cremation' Q I � 22 Time Cremation Started f Time Cremation Completed Type of Container Remarks : N 41 �� Il f/•j©- ' A-1 TOWN OF UUEENSBURY PINE VIEW CEMETERY a CIIEMFI COR I UM Oualter Road, 11uee►►sbury, New York 12804 Phone (516) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTI(OR 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 : PAULINE V. MERCIER FEMALE (Name) (Sex) 29 CENTER STREET FORT EDWARD, NY 12828 (Street ) (City) (State) (Zip Code) who died on 15TH —day of OCTOBER 19 97 at _FnRT HIMS M NIJRCTNr HOMF, FORT IWARD NY (Place) (flddress ) Name and address of nearest living relative or name of person authorizing cremation : q3 go eGp- RICHARD MERCIER FORT EDWARD NY. 12828 (Name) (Addroun ) Relationship to the deceased SON Name of Funeral Home M. B . Kilmer Funeral Home IMPORTANTs I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or tier 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 protects 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. (Wi"ess) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this dates U I SPUS I t I UN UT= CREMt1 i E U nr mn I NS I hereby direct Pine View Crematorium to dispose of the cremated remains as Follows : Mail to Other arrangements - please If pulverization of cremate remains is requested, check here__ POLICIES, "ULES nNI) REGULA T l UNS 1 . The crematorium will be open for cremations 5 days a rypp�� 7 :00 A. M. - 3: 30 P. M. Monday--Friday. No Floli day s or Sunday arrangements can bp made for- Saturday. Prearrangements ►" telephone For acceptance of remains is necessary. 2. Pine View Crematorium is located on the grounds of the Piro View Cemetery+ C]ual<er Road, Town of Clueensbury. 3. An authorization for cremation pr•oper-ly signed by the nearest next of kin or other authorized person stating than they do the power and authority to arrange for- the cremation of t► � remains and to direct the dispasit10r, of the cremated remains, that any personal possessions have either been removed or may bP destroyed and agree to protect , defer►d arid save harmless riyrP View Crematorium from any and all Claims and demands for los : rif' damages which may be made against them by reason of or cor►ne�t —i with the cremation of said remains and/or disposition of ;a ►rt remains as directed, whether such claims or demands are, or- ar,r not wholly groundless, False or fraudulent . This authoriz'- i — in addition to a regular burial permit must accompany them remains. 4. All remalins must be encased in a casket or suitable alternate container. Casltets and containers must be of combustible material. No styrafoam or plastic containers will be accepted. S. The question relative to cardiac pacemakers must be anc►+r• f � on the authorization to cremate form before the remains will t'v accepted. 6. Unless other- arrangements are made the cremated remains will be mailed via Registered U. S. Mail within three days of c rem,tinn to the funeral home handling the service. There will be a 120. 00 charge for this service. Cremation, Administration Costs and recording Fee : Adult $ 175. 00 Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn to 12 months ) t60. 00