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Adams, Calvin 7Oq+N of QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 6Q/)q Name ef&PIJ11V Case # / Date of Crematicn Time Cremation Started p �f�d 'd I l4 Time Cremation Completed D � C� Type of Container L! /11 DA'b 7 FT Z5 / 1 4LE Or 10 9y Remarks : A14/ N LIZ- "7i A// i MAY-14-1998 13:25 FROM INMAN NPTICdN!•1I£E TO 4151872506062239 P.01 FROM Panaso«i c FAX SYSfH`1 PFOE M]. May. 14 19% 01'.28MI PI TOW twr SE�RY Pi1VE VIEW GEi'E'4 faRY a CREMATORIUM Quoker Road, Queensbury, New York 22$84 phone (518) CreoatorivO 745-4477 oi- if na ancw*r Erts.&eI^Y gUTMRIZRTIQN TO CREMATE iqW The under in sign*d requests ae�tavtvaitsesR ine Rules Vand Requl,stiosts* to accordance with and sutrj cremate the regains of C0.1�/1 � tsQxJ INawe) . o (Zip Code) t5tate) istre.t) ( ;ity) — _ � day of who died on &r oQ «V 1 ' I - �L~ at `� tApdressl �� \ v t tPiaC*l Nan* and address of nearest living relative yr name of person authorizing crematiOn: � r� �"� -- hns�nW � car ,� � t Cc c r Maine) ( ddr• s) Relationship to the dede`ased C `, • �, � S c 1 1,C J Nose of Funer`aI Wage IppM.TANT: k»awled9S. the deceased has or I repreront at to the best of my (Circle One) ha no cerakQr in his ar i�er body. 2 certify that I have the full plower and authvrix&ti0v% to arrange for the cremation of the rewtafns Rrconalrd to d#possessionsrect the ;have teither the cremated remains, that any ed, and agree to protect, o*Tend been removed or aaY be destroy nd all claiss ,end save harmless Pine View Cremaiantor* + from any a` ainst then by and demands for loss or damages twhi�remation By be mof*rmVid remains as reason of as, coneeeted with ' directed, whether such claims or demands are or are not wholly /Zr/ groundless, false orfrauduie 1�,f57- �e � 4 CAA ess> EWi Hess) nr LeOsl Rep. and Add ss? 05/14/98 13:24 TX/RX NO.2245 P.001 MAY-14-1999 13=25 FROM INMAN NATICiWIDE TO 915119725-96062239 P.02 or F'RCIK Pan3.sanic FAX SYS'TB'1 PF OBE NJ. 'May. 14 19% Olt 28 f P2 DISPOSiTIaN OF CR04ATED RIE"11NS I hereby direct Pint View Crematorium to dispose of the cremated rawains as follo-*: 1 —c J Mail to Iv V, �z B— other arrangements Please apmcify� If Pulverization of cremate remains is rvquvsted� check here POLiClest iViLiEs AND �xEGl7E.ArIi7N'3 *pan for cremations 5 days- & week !. The crematorium will be No HOLidays or Su 7;0ia A-M, - 3:30 P-M. Monday-Friday• ts b arrangements can be made for Saturday. pr+tar•ra^iivi"en by telephone for acceptance of remains is necessary_ Z. Pine View Crematorium is located an thQ buryround• of the Pine View Cemetery, Quaker Road, Town Uf 3. An authorization for cremadtior properly signed by the nearest ing that theynext of kin or ether authorized parsanforat%he cremation have the the power and authoritY to arrange remains and to direct the disposition of the cremated remay b, that any personal possessions t, deefenO 4 andsavvma harmless aPfnr destrayvd and agree to Prates View Cremator-xuw fro• any and all claim% 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 Oforsare remains as directed, whether- such claims or demands are, roundless, false or. fraudulent. This awthari7&tiOn not wholly g must accompany the in addition to a 'r°gular burial permit remains_ ad in a inot e alternate 4. All remains must beencacnntainvrsaemustor beu1ofblco.mbustiblr container, Caskets a or plastic containers will be &CCep'trd. material. Via styvafoan 5_ The quvstian rrlative to cardiac pacemakers gust be A"Werod on the a 4ugst ion ru to cremate form bef ore the rawains will be accepted. de ated 6. Unlesviaherstains will RegisteredeU.!5. Mail ware aithirhthreemdatys ?fmcr'smAtian ci be paile to the funeral home handling the serwiee. �hvra will be a s20.0 charge f.pr this service. cremation, Admsnistration Costs and Recording Fe*-' Adult(stillborn Children Cage 13 Months to 12 yearv) si3,8.00 inf'arTt! ;stillborn to 12 months) TOTAL P.©2 05/14/98 13:24 TX/RX N0.2245 P.002