King, Mary uY.i�iaL_� ..........
TOWN OF QUEEVBUJ�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /, � t) po -6 '1 Case
Date of Cremation �}
Time Cremation Started /7 i'h"'l /
Time Cremation Completed
Type of Container
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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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:
Mary Ellen King Female
(Name) (Sex)
Rte 149, Box 1093 Fort Ann, NY_ 12827
(Street) (City) (State) (Zip Code)
who died on 11th day of February 99
at Glens Falls Hospital 100 Park Street Grans Earls,—NY 128n1
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
y rL T ✓7 n r� , A) I
Mrs Linda Groana R^ r—Rte 149 , t
(Name) (Address)
Relationship to the deceased ghter
Name of Funeral Home Car let Al2U.
IMPORTANT:
represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
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 not wholly groundless, false or fraudulent.
i
(Witness) (Address)
4 D D l(D
fV►� (Signature of Relative or Legal Rep. and Address) w
Signed on this date: ' ' I I
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 cremated remains is requested, check hers
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7AM`-1:30PM Monday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday.
Prearrangements by telephone for acceptance of remains is necessary.
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2. Pine View Crematorium is located on the grounds of the Pine View Cemetery,
Quaker Road, Town of (jueensbury.
3. An authorization' for cremation properly signed by the ridarest'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 or 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
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 $1,75.00
Children (age 13 months to 12 years) $100.00
Infants (stillborn to 12 months) $60.00