Loading...
Haskins, Mary T09+N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director C 2 ) -e l 01y Name Case # © S Date of Cremat i cn Time Cremation Started Time Cremation Completed Type of Container C �(�L1 (^ (��► / �-,TC'4SeCA TA Q- 0' AO( Remarks : -T 35n -M 1/ lI ry-1os i�. TOWN OF OUEENSOURY PINE VIEW CEMETERY a CREMATURIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AU t-HUR I ZAT I ON TO CREMf1 TE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of : Ka -r l i2abe (Name) (Sex) 3f Moue na.o S' Hudson Falls, AV 12Ag4 (Street ) (City) (State ) (Zip Code ) who died on Ir-+ti day of Fehraary 19 se at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation ! K • PhifA ress> ame Relationship to the deceased Husband Name of Funeral Home Clarieton Funeral Hoee Tnc IMPORTANT: I re ent that to the best of my knowledge, the deceased has or haaCemaker 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 sucF, claims or demands are or are not wholly groundless, false or fraudulent . ,041 tness) (Address) (Signature of Relativ or Legal Rep. and Address) Signed on this date : DISPOSITION OF CREMA I ED RF MF1 I NS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify : j If pulverization of cremate remains is requested, check herey POLICIES, RULES nHD 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, To�-sn of Oueensbury. 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 Fir the cremation of the remains and to direct the dispositinr, of the cremated remains, that any personal possessions have RithRr been removed or may be destroyed and agree• to protect , deFenrl 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 sl.tch claims or demands are, or are not wholly groundless, false or fra1.Ar1ulent. 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 cnntainPv,s 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 ,3 months to 12 years ) $ 100. 00 Infants ( stillborn to 12 months ) $60. 00