Evans, Marie 70gtiN OF QUEEN4.5BU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director a6 L 1'z+ K
Name (� l �� 1i�� Y Case # G—
Date of Cremation
Time Cremation Started
Time Cremation Completed 2, l
Type of Container CArFzc) A d l� iv-r—
Remarks :
A1,41 N 1-0 V� /✓1,
All.
TOWN OF QUEENSHURY
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:
a, Cu a- ,
(Name) (Sex)
(Street) / (City) (State) (Zip Code)
who died on / _ day of Q ��� CT�� 19 9(:F
at 2l - Cf'V►�sZ
( lace) (Address)
Name and address of nearest living relative or name of person
auth izing c mation:
(Name) (Address)
Relationship to the dec ed 4&q ML
Name of Funeral Home G
IMPORTANT:
1nMresent that to the best of my knowledge, the deceased has or
has no p cemaker 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 such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) dress)
3 ,3 ( (A ko '4 a'-0 al— N
(Signature of`-Relative or Legal /Rep. and Address)
Signed on this date: Cad•
DISPOSITION OF CREMATED REMAINS
I hereby direc
t Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
arrangements - please specify: check here__
other nested,
If pulverization of cremate remains is req
POLICIES, RULES AND REGULATIONS
for cremations 5 days a week 7 :00
1 . The crematorium will be open No Holidays or Sundays ,
3 . 30 P .M. Monday-Friday• prearrangements by
A.M. - Saturday•
arrangements can be made for
telephone for acceptance of remains is necessary. *
View Crematorium is located on the grounds of the Pine
2 , Pine View Cemetery, Quaker Road, Town of Queensbury•
3 . An authorization for cremation properly signed by the nearest
person stating that they do have
next of kin or other authorized ne for the cremation of thethat ains
ny
the power and authority be destroyed
and to direct the disposition of the cremated remains ,
personal possessions have either been r save movedhale or ss Pine View
and agree to protect, defend and
Crematorium fes
rom any and all claims andreasone of ormands fconnectedfwithathe
which may be made against them by
or demands are, or are not wholly
cremation of said remains and/or disposition of said remains
to
directed, whether such claimsation
soundless, false or fraudulent•coThis
the remains .
in addition
g perm must accompany
a regular burial p
casket or suitable alternate
4 . All remains must be encased inmust be f combustible material.
container. Caskets and containers
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 e
accepted.
6 . Unless other arrangements are made the cremated remains will be
mailed via Registered U.S- thelservice ithinthrThereywill be ma t$20.00
the funeral home handling
charge for this service.
Cremation, Administration Costs and R1r00ng Fee: dult $195 .00
(stilltorn to
Children (age 13 months to 12 years) $ 15
12 months) $75.00
* Additional $50 .00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50. 00.