Cing-Mars, Robert TO q+N OF QUEEN,sBUSY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &,9 z
Name Case #
Date of Crematicn C� i
Time Cremation Started Q L�
Time Cremation Completed Q, —C) 1`) /Vj &,X) U) -
Type of Container
e G4 S C-
Remarks : �%
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11 ll 1 �All .
TOWN OF GUEENSBURY
PINE VIEW CEMETERY
�4
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 774-44776or if no answer
Cemetery
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:
Robert Jay Cinq-Mars Male
(Naas)
(Sex)
18 Fourth Ave. Renwyck Place Rensselaer, NY
(Street ) (City) (State) (Zip Code)
who died on
3rd day of August 19 99
at Albany Memorial Hosoital , Albany, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mary Brzustowicz 450 Oakdale Drive Rocheshpr , NY 14618
(Name) (Address)
Relationship to the deceased
niece
Name of Funeral Home William J. Burke & Sons Funeral Home
IMPORTANT: knowledge, the deceased )43 ►i(
I represent that to the best of my 9 +
XRK
has no pacemaker 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.
(
(Address)
(Witness)
( �450 ester
Signa ure of ive or Legal Rep. and Address)
Signed on this date:
August 5, 1999
V
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify: cep
If pulverization of cremate remains is requested, dheck he
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 ielati-tie 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 (stillb n to
12 months ) $75 . 00
* Additional $50 . 00 charge for cremations 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays wj� be
charged the additional $50 . 00.
FROM FAX RHO. Aug. 06 1999 02:16PM P3
08r05�1999 13:39 513-58d-•a14/ �uwi. J. +.,�JR�.G tk JL++y • ••�
TOW OTi98tJRY
pIW$ VtEw CXMETERr
A
GI&pWTCIH IUM
Rv�tl. O,eensduryj Mew York 1�Bm4
Quak r 745-4477 or if Ro answer
Phone t'„'1 ) GremC*oetery 745-4476
FjUTHOftLZATIOK TO CpFAATEuiew Crematorium. in
The und*rst9t+*d requests +e4autoQitses Ping Rules and Regulations t4
aadordona■ with A"d sub,
cremat* the reMsins of Male
Roberts Jay Cinq-Hass
(smx>
Name)
is Fourth. Ave. Ronwyck Place Rensselaer# `tiip COW�litr*et)
(City) is ate)
wh0 died an
3rd day of a►-�ougti - 1�► 9g.-
at Alban(place)M aCial.
tAdtlres>>
Name and address of nearest living relative or name at person
gy
wuthorisinq erematzv^� 8
Mary BrzUB owlet tgddr►sss)
t Meow)
Relationthly to the deceased
p�CCe
Nose of Muneral Home
William J• Buxae & Sons Funeral HOW
IP POIITRNT t the d*caw s ad 7ilOf01t1g K
I represent Chet !* the east of OV knowledge,
has me pademak*so it tits or her body. tGirrie Or*>
I Certify that I 'love the full P*wov" and auth+ori=atian to arrange
for the eremmdrem of the tmaths ^donal direct
pas*as*tans'M'aveteither
IVVl of
the cremated remain*, that any P
relleVsd or maY d* destrryed, and agree to, preteet, defend
been
ae yaro narraters Pine View Grematvrium from any and all claias
and demands tot- loss or damages which may be mad* ,*painst them by
reason of or cOt�"*Etta with the crr'matie/1 at said remains as
directed, whether such Claims or demands are or are not wholly
false fraudulent.
it
(Wltness� tAddress�
cdigni ura vf4 rlati�* er t.egal Rep. and• Address)
Signed er this latex
August 5, 1999
I
08106!1999 1:: 59 516-524-014' WNI. J. BURKE E. 'OHS PAGE 01
FH;4 NO. Aug. l6 19 9 02 16F'rl P3
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a�105;1y99 13:3? 'S:c A 1
TOWS
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46
GIdOaroft tum
�HAk�r RvaO. Oufqrn*burV, New yvrk x29e'►
Pronf t`:lIJ Crfawtoriva T& 5-4477 or if no answ4r
G fafterY 74','-4l�T6
FWTMAjjpT10N TO CWAMp,tEv{ew Grteatvrtue. in
Tl1t undfrllQned rrquelt9 •pd OVLllorssfsVirl* e
Rvllfs and lrtian t0
,CCOro4Lna• with ano sub;act to ►ts
Crewot0 the rfoa►ns of Male
3a� Oxaq..pgaCs
Rob*r t (SOP)
(Nos*)
AQnVYC Piacre Rroneaelaor, NY
i8 Fourth Avo, State; grip Code)
(City)
�ftrfetJ ay A st i♦ gam...
who died an ..3rd
of
�t A sr► eri tpWdrsssl
t 460
nsef Of
Pisoe and of nearest ]ivir� relatl�e os"
d a Dcrfo�
aatmOri:inp erosetia»a iy g
mar Br 1a Yi r. tAdd�'eOsJ
f"680 1
Rqlatiot1ih10s to the dfCOaMetl
tSl�ce
William 3. Buzico & Sct�s FuneCai Home
"mss of Runeral 3ioA0
111PONT�s the aese of Sy kno"ledees ttte doCOAtwillilOiAC
i *epresem that tod (Ctrclo 0»0>
ho,o n0 peevook0r i tt h t• ar, her .beY•
i certify thft l yave thv full power and to M1"ranet
a�rthvrisatta+n
for $h0 Crecotlon of the hP&0;nys�+/x+sonal 1PPt/te/ierisreCt the e Piave tfttho
tt+e crgoot0d reoolns, t and agree t0 protect• d►ft"d
been r+egevtd yr may 00 dsstreyed, 9 All. eloses
e save naretfst pine Vtt» CrWoosoriva fro• any ind OY
aao saveggea Ma gibfor toss or ddSolog w►t;Ch May be Made opeinrssthoo Of
roagob of or cehnerted with the cgw'v j a of se►a
dircCtedq ti+�lethar even claias 0r droand* are or art not ►�he1ZY
erevnOtessr !s!1�e or fraudulent•
` � tAddwrss� V
lWitress►
�fi 4ns awe v f� rlot i t0 a Lbowl Reps orio, Addr'eOwJ
on thxis`.dstci
August 5, 1999