Durkee, Maria TOWN OF QUEEN,5BU-Iky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6//940- /Q /4
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Time Cremation Completedl6 idQ &M
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
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:
Karia Tianao Durkee Fewale
(Name) (Sex)
Yeet.ount Health Facility Queensbury. MY 12804
(Street) (City) (State) (Zip Code)
who died on 22nd day of April 98
at V-etmol-a,t Nestth Care FanitityGurney Lane Dueensbury. NY 12804
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
11r. Thm-an G. Durkee go saftleFd St.
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Carleton Funeral Howe Inc.
IMPORTANT:
represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
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 such claims or demands are not wholly groundless, false or fraudulent.
& k
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Pas Cz
DISPOSITION OF CREMATED REMAINS
hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements - please specify: _
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7AM-3:30PM Monday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday.
Prearrangements by telephone for acceptance of remains is netessaryt
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 or loss of damages which may be made against thejn 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.�ih 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
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 13 months to 12 years) $100.00
Infants (stillborn to 12 months) $60.00