Doblin, Rudolph To 7+N OF QUEEVBUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ' /\
Name J&bL2tf/7' �C��fr/� Case 0 �1
Date of Cremat i cn __ 1-'27 2y�
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Time Cremation Started � ;—'yi M I
Time Cremation Completed43!(P
Type of Container
Remarks :
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TOMB Or CLAW RSURY
PINE VIEW CElfETERY
bb
' C!t£MATOIS I UM
Quaker Road, Qusensbury, Now York 12804
Phone (518) Cremotortu■ 745-4477 or if no answer
Cemetery 743--4476
AUTHOHIZATION TO CREMATE
The undersigned requests and authorizes Pine stew Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the
/.�remains
oft
1
L A 1
(Street) (City) (State) (Zia Code)
who died on day
at Y1 ` Cl
tplace► (Addros )
Maas and address of nearest living relative or mane of person
authorising creaat3ont
(Name) ( !zeal
Relationship to the deceased y
Mae* of Funeral
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or htr body. (Circle One)
I Certify that I have the full power and authorization to arrange
for the ereaation of the remains and to direct the dispesition of
the Cremated re*&ins• that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
ind save harmless pine View Creaatvriva from any and all claims
and demands for loss or damages which may be made against then by
reason of or connected with the creaati0n of said remains as
direetede whether such Claims or demands are or are not wholly
gveRundloss, fats• or fraudulent
H 0 LP
(Witness) (Address)
-X—
tRigna r• of Relarrt��ive or gLepal qep. a»d Address)
Signed on this date:
DISPOSITION_;,OF,.CR$MATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify:_
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.
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
the authorization to create form before the remains will be
accepted.
6 . Unless other arrangements are iadej•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 $195.00
Children (age 13 months to 12 years) $115.00 Infants (stillborn to
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.