Baker, Baby TOWN OF QUEENs5BUI�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Direct or4ddg
Name "g, Case # 0 y
Date of Crematicn_ �
Time Cremation Started l g I �S-7�� /- IM I
Time Cremation Completed / //y'-��l IY i 1
Type of Container CjAR A6AJ?P 9*.p
Remarks :
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FEB-06-98 FRI 16: 19 CHP 3RD TOWER BUILDING FAX N0, 5187821679 P, 01
TOWN OF (aUEENSSURY
PINE VIEW CEMETERY
a
CREMATOR LUM
Quaker Road, Queensbury, Nerj York 12804
WhOne lS18) Crematorium 745-4477 yr if no answer
Cemetery 745-447E.
it
AUTHORZ Z'AT10N TO CREMATE
accordancewit
?'he uncle*=5� w r�equesta and authorizes Fine in View Crematorium,with requests
subject to its Rules and RsgallaCxons to
cremate the remains of:
*Z11 leL1011— d
(N3 a ) (Sex)
(Street)
(City)
who died an j ,ay of �4
at
( lace) (Address)
Name and address of nearrst living rwlative or.authorizing cremation: name of person
1-7
(Name) (Oddres s) jy4c,4u7' A)4-/
Relationship to the doa"A%ed
Nam* of Funeral Homa�✓� � [' - SOi+t�'J� �LXA1,F 1
I MMRTANT s
l re resent that to the best of my knowl@dge, the dree�tsed has or
has na Pacemaker in his or hvr body. (Circle One;
1 certify that I have the full power and authorizaticil to arrangm
for the cremLk ion of the remains and to diroct the disposition of
the crrmated remains, that any personal possessions have eltM er
been rempVdd or Ray be destroyed, and agree a to protect, defend
and save harntlsss Pint View C""torium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connoctod with the cremation of said remains as
dirvatfdq whether such claims Or demands are or $re not wholly
less, f lse Or fr dulent.
( Hots)
t
t8ignature of el five or Lagal Rep. .tnd Addremas)
Signed on this date! e2?~ (0. rr- q;/1-
A
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify : �s Lil-L
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 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. N- s, yrafoam 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 f15. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $155. 00
Children (age 13 months to 12 years) $90. 00 Infants (stillborn
to 12 months) $50. 00