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Wells, Robert 7O`74N of QUEEVBUPY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Directorltil � lJ Name �ti.�l/� �� �d /ff`? Case # Date of Cremation / /✓ Time Cremation Started Time Cremation Completed �`—y�= h 11' Type of Container Remarks : Ailq NAli l y� 1/ lI !'J ,r 3 TOWN OF OUEENSBURY PIW VIEW CEMETERY R CRF-MATOR I UM ^;maker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or -6f no answer Cemetery 745-4476 AUTHOR I LpT i0N TO CREWS reouests ar:! aa:=for=�- ^tie View Crematorium, in The undersigned . 44k Rules and Regulations to accordance with and subject cremate the remains of Male Robert J. Wells t5eK) (Nam!) Cascade Acres C-41 Lake Placid, NY 12946 (City) (State) (Zip Code) (Street) 19 99 March who died on 4th day of at Adrk Medical Center, Saranac Lake, NY (Place) (Address) Name and address of nearest living relative or nam1 of person authorizing cremation: C-41 Lake Placid , NY 12946 (Name) (Address) Relationship to the deceased Wife 7 Saranac Ave. , Lake Placid, Name of Funeral Home NY 1 IMPORTANT: knowled a the deceased has or his I represent that to best of my (Circle One) has no pacleaker in his or her body. ve the full power and authorization to arrange I certify that I ha d to rect ion Of for the cremation of the regains 'rsonaldipossessionss have teither thebeen cremated remains, that any p n been removed or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any and all claims hem by and demands for loss or damages which may be made against mains as reason of or connected with the cremation of said such claims or demands are or are not wholly directed, whether groundless, fals e or fraudulent. Ar- Ave. r Lake Placid, NY 12946 an (Address) t fitness) 12946 AI Cascade Acres C-41 , Lake Placid, NY al Rep. and Address) (Signature f Rel�tive or Leg A March 5 , 1999 Signed on this dates i DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to M. R. Clark, Inc 27 Saranac Ave./, Lake Placid, NY 12946 Other arrangements - please specify: If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 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 farm before the remains will be accepted. 5a unless other arrangements are made the cremated remains will be m*iled *r .a Rs^i.stered U.S. Mail within three days of cremation to the funeral home handling the service. There will be s $20.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $195.00 Child-ran !age 13 months to 12 years ) $115 .00 Infants (stillborn to 12, mow�.-h3) $75 . 00 * Additional $so .00 charge for cremations done after 3 :00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50.00.