Chase, Jean rlO WN OF QUEEN4,5BWKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case #
Date of Cremation
Time Cremation Started
1 *n
Time Cremation Comp1etedgo! Q tI 1'
Type of Container C— !/yCiL.�
Remarks :
get t
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TUQN OF OL"NSAU"
P I NE Q I EW CEh1ETERY
a
CREMPT13RIUM
Quaker Road, Queensbury, New York 1 d04
Phone (516� Crematoriuo74544776or if no answer
Cemetery 5
AUTHORIZATION TO CREMATE
The undersigned requests and a4thorires pins View Crwmatvri%Aut in
AccordanCe With and subject tv its Rules and Regulations to
cremate the remains ofs
�P.dl� fl. C?�aSe
Female
(sex)
cNaa��r>
11 Roosevelt. Avesnuir Mlecinta New York 13820
t$trvet ) kcity) tStale) (Zip Code)
who died on
loth day of klarlua,zy
St. Peter's Hosvital Albany, New Yorx
a
(Place) (Address)
Name .and address of nearolt living relative or n*ae of ptrsan
authorixxng cremation:
Timothy D. Chase 47 Ladwovd Driv2r Holmdel, N.J• 07733
(Name) (Address)
Relationship to the dectased
Son
Nana of Funeral NaAe 13rewer Faneral HOM?.
. Ilz�•
I WORT MT d the dreeesed has ar
I repreownt that to the best of my knowlege,
ors noo p c aker in his or her body+ iCircle One)
I certify that I have the full power and au'thorizotion to arrange
for the cremation of the remains Arid to direct tsivrdishaveteOther
of
the cremated remains, that any persl agree to prpteCt, defend
been removed or may be dQstr"vyed, and a 9
and save harmless nine view Crematorium, from any and 01.1 c18i"
h may be made o
and demands for 19$s or damages whicid remains s by
o sa
reason of or connected(with the
fais cremation
reorare r►otwholly
dire totes W
demands 0
grow Bless Eels r fraudulent.
t
x (Witn ss) (Address)
X Anti Address) —�•,••
tgignature of Relativr oY- Legal Rep.
7C Signed vn this datet
DISPOSITION OF 'CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated ,
remains as_followss
Mail to
19773 -T� .
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
I. 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 s2O. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult s185. 00
Children (age 13 months to 12 years) i
to 12 months) s70. 00 11,O. O0 Infants (stillborn