Kastor, Joseph TOWN OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '
Name s 'J / jy A057 zY Case #
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Time Cremation Started
Time Cremation Completed �/ � 40
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TOWN OF UUEEN98U"y
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
in
ts and
The undersigned
tihrandessubjectautooitsesRules pingVand Regulationsiew Crematorium/ to
accordance
cremate the remains ft
ts:a,na) (SON)
C�
(Street )
(City) ate) (Zip Code)
qq
who died on
day of 19
a t V "q- 1 1
tPlacel (Address
Name and address of nearest living relative or name of , person
au orizing cre ationt
;L I
(Name) (Address)
Relationship to the deceased
::�Name of Funeral Nome
IMPORTANT$ Nnowled a the deceased has or
went that to the best of my (Circle One)
As-po no pacemaker in his or her body.
e the full power and authorization to arrange
I certify that I hav
for the cremation of the rem ains lrsonald to dipossessionsrect the shaveteither
the cremated remains, that any p defend
been removed or may be destroyed, and agree to protect,
and save harmless Pine View Crematorium from any and all claims
made against thew by
and demands for loss or damages which may be
reason , whethernsuchdclaiw with s ore cremat demandsoareoorsaare not remawholly
directed,
groundless4 false or fraudulent.
(Witness) (Address)
(Signature of Rel ve or Legal Rep. and Address)
2
Signed on this dater
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 ss 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 cremate form before the remains will be
accepted.
6 . Unless other arrangements are made 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 .
i
I
"Customer's Designation of Intentions"
Name of Deceased.
s 1 f
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy,of
this form.
(Signature)
fated Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Nam ounf Funeral Director Signature of feral Director Date
or dertaker or Un�zrtaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
• Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 -