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Waite, Bruce 70`4N OF QUEEVBWU PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director L4M/.. 7ON Name /)CF" a. �A ! Case # b� Date of Cremation ! © r Time Cremation Started bi �h fAA Time Cremation Completed ' r 1M -� Type of Container D9o11RD /S / Remarks : 1414 r 0901VA W o/v r r 11 11 F`/AA �� i TOWN OF OUEENSBURY PINE VIEW CEMEtERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 numoRIznTIUN TO CRF_mnTE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: Bruce Carlton Waite Hale (Name) (Seat) Box 48, Waite Road Ring bury 1= :4Q (Street ) (City) (State ) ( Zip Code) who died on '24th day of Octebe.- 19 C17 at amuel Stratton Veteran's HoSPNew Scotland Ave. Albany. NY (Place) (Address) Name and address of nearest living relative or name of person autHori ? ing cremation : Mr. David Waite Hoes 42A, South Johnah rg RnAd (Name) (Address) Relationship to the deceased Sorg Name of Funeral Homr.Carleton Funeral Horne Inc. IMPORTANT: I 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 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 io ly undless, false r- fraudulent. (Witness) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date : DISPOSITION OF CRFMATFD RFMf1INS I herchy 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, RULES nmi) RFGULAT I ONS 1. The crematorium will be open for- cremations 5 days a week 7:00 A. M. - 3: 30 P. M. Monday-Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance of remains is necessary. 2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3. An authorization for cremation properly signed by the nearest next of kin or other authorized person stating that they do have the power and authority 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 of damages which may be made against them by reason of or connected with the cremation of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular burial permit must accompany the 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 answered on the authorization to cremate form before the remains will be 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 1 ,� months to 12 years ) $ 100. 00 Infants ( stillborn to 12 months ) $60. 00