Howe, Sandra TURN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Lkmgx,
Name e�AAyx/7 Z/2ogg— Case # 'T
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Containery
Remarks:
A1,41 N
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1 i •� 131,44
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1*0WN OF (](IEENSUURY
1I I NE VIEW CEMETERY
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Qualrer• i7oaci, 1]ueensbury, New York 12AO4
Phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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AUTI I0II I ZnT I UN TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains ofs
Sandra Howe Female
(Name) (Sam)
RD 2 Box 2064 Fort Ann, New York
(Street ) (City) (State) (Zip Code)
who died on 44th __day of Nov 19 97
at her home
(Place) mdciress )
Name and address of nearest living re) ative or name of person
authorizing cremations
(Name) (Addroun )
Relationship to the deceased husdand
Name of Funeral Home
M. B . Kilmer Funeral Home
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 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 .
.8
ass) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date : Nov. 5, 1997
U I SPOS t r i UN Or CREMAi EI) Rr-Mf•I NS '
I hereby direct Pine View Crematorium to dispose of tt,e cremated
remains as follows :
Mail to
Other arrangements - please
If pulverization of cremate remains is requested, check here
POLICIES, RULES ANI) WGULA 1 l UNS
1 . The crematorium will be open for cremations 5 days a wppi�
7 :00 R. M. - 3: 30 P. M. Monday--rrid.Ry. NO Hot idays or runrlay' ,
arrangements can bP made for SAtur-day. Prearrangements t ,
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the pins,
View Cemetery+ Quaker Road, Town of Queerrsbury.
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 of thn
remains and to direct the disposition of the cremated remains,
that any personal possessions have either been removed or may hP
destroyed and agree to protect, defend and save harmless rirrp
View Crematorium from any and all claims and demands for Iosl r
damages which may be made against them by reason of or conrlec't -rl
with the cremation of said remains and/or disposition of ;al.i
remains as directed, whether such claims or demands are, or -Iry
not wholly groundless, false or- fraudulent. This author-iril- i
in addition to a regular burial permit must accompany t1im
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.
S. The question relative to cardiac pacemakers must be anrisr- f -
on the authorization to cremate form before the remains will t-v
accepted.
6. Unless either- arrangements are made ttiP cremated remains wi 1 l
be mailed via Registered U. S. Mail within three days of crem;itinn
to the funeral home handling the service. There will be a $20. 00
Charge for this service.
Cremation, Administration Costs and Recording Fee : Adult S175. 00
Children (age 13 months to 12 years ) i100. 00 Infants ( stiIIhorn
to 12 months ) i60. 00