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
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Name �ti.�l/� �� �d /ff`? Case #
Date of Cremation / /✓
Time Cremation Started
Time Cremation Completed �`—y�= h 11'
Type of Container
Remarks :
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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.