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Fleming, John TOq+N OF QUEENSBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name ITC71IN Case #i Dat e of Cremation — '/ `� 2 Time Cremation Started2l© z /4-f 1 J P Time Cremation Completed rle -,AO Type of Container Remarks : 1/1 TOWN OF UUEENSDURY PINE VIEW CEMETERY (� a 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 : 3 o k vck t'vvm "-P\ (Name) (Sem) (Street ) (City) (State) (Zip Code) who died on day ofAa_A_qm 19 ( ^ f at MaAntj (Pla e) (Addre s) Name and address of nearest living relative or name of person authorizing cremation : Kc&" R 2eZ &cz�,,QAs La-t-k- SoJ AN (Name) (Address) Relationship to the deceased Name of Funeral HomeM�-ClC l(ar1. f TkAA CA 0 L HDVAL IMPORTANTs resent that to the best of my knowledge, the deceased has or has no acemaker 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. z�'6S (W ess) (Address) i _ (Signature of Relative or Legal Rep. and Address) Signed on this date : �131�9 DISPOSITION OF CREMATED 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' b.e open for cremations 5 days• a week ' arrangements can be madedaforrSaturclallo Holidays or Sundays, y. telephone For acceptance of remains is necessaryearrangements by 2. Pine View Crematorium is located- on the grounds of the Pin View Cemetery, Quaker• Road, Town of Queensbury. e 3• An authorization For cremation next of {tin or of{iNr. authorized properly signed by the nearest the Power and authorit Person stating that they do have y to arrange for the cremation of the remains and to direct that an the disposition of the cremated remains, Y personal possessions have either been removed or destroyed and agree to protect, end may be def 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 remains as directed, whether such claims or demands are said not wholly groundless, false or Fraudulent. in addition This authorization to a regular burial remains. permit must accompany the 4. All remains must be encased in a casket or suitable alternate container. Caskets and material. containers must be of combustible No styraFoam or plastic containers will be accepted. •5 The question relative to cardiac on the authorization to cremat Pacemakers must be answered accepted. e form before the remains will be 6• Unless other arr•angemerts are made the cremated remains will be mailed -via Register ed U. S. Mail within three days ,of cram to the funeral home f,andlin charge for this service. g the service. cremation 'there will be a $20. 00 Cremation, Administration Costs and Recordin Children (age 13 months to 12 g Fee: Adult S185. 00 to 12 months) s`j0. 00 Years) sl ..0. 00 Infants ( stillborn