Noble, Walter TO UN OF QUEENJ,5BU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director jr&7m 4cpA-�i►/�
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Date of Cremation
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Time Cremation Started
Time Cremation Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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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:
Martha A. Herrman Female
(Name) _ (Sex)
10 Ashe Drive Warrensburg New York 12885
(Street ) (City) (State) ( Zip Code )
who died on 29th d a y of December 19 98
at Porter Hospital Middlebury, Vermont
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Evelyn L. Pullen 12 Meadow Way Middlebury, Vermont 05753
(Name) (Address)
Relationship to the deceased niece
Nave of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased XQ(AXXXC*X
has no pacemaker inXKXMX(XXXher 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 , defena
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them b`
reason- of or connected with the cremation of said remains as
dire,6i ed whether such claims or demands are or are not wholly
gro ndl s , false or fraudulent .
(Wi ness ) (Address)
(Signs re of Relative or Legal Rep. and Address)
Signed on this date : January 2, 1999
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Miew Crematorium t dispose of the cremated
remains as follows : /
Mail to
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
L. 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 fir cremation properly signed by the nearest
next of kin or other authorized person stating that they4do 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 $185. 00
Children (age 13 months to 12 years) i11.0. 00 Infants ( stillborn
to 12 months) $ 70. 00
.-
I HEREBY EXPRESS TO MY SURVIVORS MY EARNEST DESIRE AND REQUEST THAT ONE MY DECEASE MY BODY SHALL
BE CREMATED AT PINE VIEW CREMATORIUM, ON QUAKER ROAD, TOWN OF QUEENSBURY, NEW YORK AND FURTHER DO HEREBY
ORDER, DIRECT AND AUTHORIZE SUCH CREMATION.
(Signed)
(Address)
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Dated
TO BE ENTRUSTED TO THE SIGNER'S EXECUTOR OR NEXT OF KIN
(Return copy to PINE VIEW CREMATORIUM, Quaker Road, Queensbury, N.Y. 12801)