Ouellette, Carol TO q+N OF QUEEMSB 9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1,fi0-rk1-- '1Y
Name L�A?Ij ��i. /�/,1�// /� Case
Date of Cremat i cn 11>
Time Cremation Started
Time Cremation Completedq
Type of Container /i�l� � � //��► � ���' �� a�
Remarks :
TOWN OF QUEENSBURY
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
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
Carol Ann Ouellette Female
(Name) (Sex)
1194 Burgoyne Avenue Fort Edward, NY___ 12828
(Street) (City) (State) (Zip Code)
who died on 27th day of February 99
at 1194_Bur&ovne_Aye�, Fort Edward,
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Kr Roland A- Ouellette 9A 0. - --
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Carleton Funeral Home Inc.
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.
(Witn ss) (Address)
// L2 zz__e4:;'
(Signature of Relative or Legal Rep. and Address)
Signed on this date: ----
DISPOSITION OF CREMATED REMAINS
hereby direct Pine View Crematorium to dispose of the crernated remains as follows:,,
Mail to --- - ----—— ---- ----
Other arrangements - please specify:
If pulverization of cremated rernairns N requested, check here---..-
POLICIES, RULES AND REGULATIONS
1 . The crematorium will-b'e open for cremations 5 days a week 7AM-3:30PM 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 1do have=the power and authority,to arrange for tihe
cremation of the remains and to direct the disposition of the crernated 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 there 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 combustfbW material. No =slyrafoarn 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 $195.00
Children (age 13 months to 12 years) $100.00
Infants (stillborn to 12 months) $60.00