Jasper, Amber rl-nq4N OF QUEEN5BUCRY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 9C , / a 0d,/4v
Name /Vl� /1 / .��case #
Date of Cremation
Time Cremation Started�i' �(5 /9 rM
Time Cremation Completed / /Ibo 00, im
Type of Container 117`13,t- Pz�ly
Remarks:
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TOWN OF QUEENSUURY
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:
_ AM 6eR Tnr—.rQeA F-
(Name) (Seri)
iC-5ynce-'Kc� i cam-. �l j Z�3
(Street ) (City) (St te) (Zip Code) qq
who died on fo1 day of ��� 1g�
,at �t �- IL-(/tCf'_.Vl lJJ^t �,�CI T CIO 34
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
&)n2LC- r S lU�
(Name) (Address)
Relationship to the deceased �Y
Name of Funeral Home
IMPORTANT:
I sent that to the best of my knowledge, the deceased has or
has 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.
AIAI
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date :
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 cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
I. The crematorium will- b.e 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, Gluaker' Road, Town of Oueensbury.
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 clams 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 form before
accepted. the remains will be
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 s20. 00
charge for this service,
Cremation, Administration Costs and Recording Fee:Children (age 13 Adult i1135. 00
months. to 12 years) $ 11.0. 00 to 12 months) s`j0. 00 Infants ( stillborn
r 9*Cletlan Tuneral &mice
19 6st 1�°roadroay
c5oleta 9Yev Work 12865
518-6511-3555 `Tax 516-654-3600
,9on cS 9VcClellan .Oic cTuneral Director-9y1anager
` Gra `}tanks Cfuneral"Irecfor
April 12, 1999
TO WHOM IT MAY CONCERN.
McCLELLAN FUNERAL SERVICE HAS PERMISSION TO CO-MINGLE THE
CREMAINS OF FIVE DECEASED MEMBERS OF THE SAME FAMILY- THE BODIES
MAY BE CREMATED CO-MINGLED IF NECESSARY.
JOHN C. WAITE JR.-CHERYL JASPER-AMBER JASPER AUTUMN WAITE-TYLER
WAITE.
I
TOWN OF UUEENSDURY
PINE VIEW CEMETERY
a
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:
6U:t t AW E
(Name) 9d Gr �/�( 11 ( �/� (Se»)
NA _J?1�M_
(Street ) (City) (State) (Zip Code
who died on �/1�'� day of AD>Fr ' ) 19 _
.at ,� �D(.tJ�(In Ill• T�(e e,1/Lt1�I r,ln� ► N \4 17i 11
r)3�7
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Address) t�-
Relationship to the deceased J 1 ��� IIr4V �1
Name of Funeral HomeAC JfJJQ-K �;,k_Wt
IMPORTANT:
esent that to the best of my knowledge, the deceased has or
Ch2!:s._: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
ground 5s, false or raudulent.
(1 j,#/C( -
&__ 64;eA 4 '
y Witness) (Address)
(Signature of Relative
sa or Legal Rep. and Address)
7
Signed on this dates 1i'-L�
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 cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1, The crematorium will' b.e open for cr•emat.ions S days- a A. M. — 3:30 P. M. a week
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, Uuaker' 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
that the cremated remains,
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
not wholly or demands are, or are
groundless, false or fraudulent. This authorization
in addition to a regular burial permit
remains. must accompany the
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.
S. The question relative to cardiac
ers
on the authorization to cremate form before remains must be answered
lred
accepted. the
be
6, Unless other arrangements are made the cremated remains will
be mailed -via Registered U. S. Mail within three days of cremation
to ttie `un.aral home hancil i ng the service. There will l be a f20, 00
charge for this service,
Cremation, Administration Costs and Recording Fee: Adult Children (age13 months to 12 years) tl].0. 00 f1a5. �D0
Infants ( stillborn
to 12 months) t110, 00