Bates, Robert 7owN of QUEEVBU-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &�E'4Ag4 2,EJ--Vjy
Name Aeha7— gdTAr- Case #
Date of Crematicn ! 9-3 W
f
Time Cremation Started l2 4 1 AI
Time Cremation Completed
Type of Container J66D G/451t-,6�-7-
Remarks :
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I r TOWN OF QUEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (51B) Crxebatorium 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 :
(Name) _ (Sex)
&yWs F i/vu 2�- 20^ 60, is LAWS lLfi tt S A'�
(Street ) - (City ) (State) ( Zip Code )
who died on day of 19
at
(Place) (Address)
Naim,e; and , address of nearest living relative or name of person
a.ut►hori.z i ng cremation :
>r
(Name) , (Address )
Re•lat i`onship ,t•o the deceased
Name .o{fFune.ral Home cS4_1�(, A—
I MPORTANT.r
sent' 'that ' to the best of my knowledge, the deceased has or
ha`s no pacemaker in his or her body. (Circle One)
cert`'i'fy'''that I ' have the full power and •aut:horization to arrange
`f'or" the ':cremation of the remains and to direct the disposition of
,,L 'I ' 1 1 1' P
the' crexated '• remains, that any personal possessions have either
been r. esro,ved or may be destroyed,, , and , a,greP to protect , defend
ix •1 .� p.
and.: s'ave:..harmle.ss'1Pine View Crematorium from any and all claims
and!E'demands`{1or�"'l�oss' or damages which may be made against them by
reason' of. or connected with the cremat.•io.n of said remains as
directed, whether such claims or demands are or are not wholly
group 1,es's�;°:'faIs'e,, r f'r dole t . `
fitness) (Address )
" (Signature of Relative o Lepal Rep. and Address)
C
Signed on this dater ��
DISPOSITION OF CREMATED REMAINS
I hereby 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 AND REGULATIONS
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 clalms. 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
on Caskets
Caskets and containers must be of combustible
m'at'er'i)al?. 'No styrafoam or P
'I Ayf;,,; .e.�,t�,.s plastic' will be accepted.
r" s:0)a The rquestion re1ativ�e to card'_ac pacemakers must be answered
„ l onl, the;'aI V,;IV ;,rization' to . cremate form before the remains will be
accepted '„._
6•" ' Unles's other arrangements are made th.e cremated remains will
be mailed -via Registered U. S. Mall within three days of cremation
to the funeral home handling the service. There will be a t20. 00
char..ge...for--•this - service.
Cremation,' Administration Costs and Recording Fee : Adult s1p5. 00
Ch,i_1•dr..e.n.,.,.�„(age._. 13 months to 1- years ) sl ],0. 00
t 0 Infants ( stillborn
12 mo�nth�s')`tW4$`j0. 00