Waite, John Tyler Jr. 70 WN of QUEEN,.,5Bu-, �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director AC 4
7j�Name t1 Case #
Date of Crematicn ?C�
Time Cremation Started
Time Cremation Completed y" o /7 � ►"
Type of Container/
Remarks :
r1q
TOWN OF QUECNSDURY
�
PINE VIEW CEMETERY
!L
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: /U/►
(Nam*) (Sem)
16 "11 yk�
l�l 123
(Street ) (City) (S ate) (Zip Code)
who died on Z--- day of yA 191A
.at IUJDL�'rw- U. 0\4 12'e3q
(Place) (Address)
Name and address of nearest living relative or name of person
a thorizing cremation :
(Name) (Address)
Relationship to the deceased
Name of Funeral Home AAQ:�&
IMPORTANT:
sent that to the best of my knowledge, the deceased has or
has pacemaker in his or her body. (Circle One)77
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
grow Bless, false or fraudulent.
(Witness) (Address )
I
(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
reniains 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 cr•emat.ions 5 days
- a A. M. - 3:30 P. M. a weekMonday-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 leave
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
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.
5. The question relative to cardiac
nswe
on the authorization to cremate form before kthe remains ers must be awillred be
accepted.
6• Unless other arrangements are made the cremated remains will
be mailed -via Registered U. S.
to the Mail within three days of cremation
funeral home handling the service. There will be a $20. 00
charge for this service.
Cremation, Administration Costs and Recordin
Children (age 13 months to 12 9 Fee: Adult t185. 00
to 12 months) t`)0. 0P1 Years) 31 ].0. 00 Infants ( stillborn
TOWN OF UUEENSDURY 1�
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) 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:
( ma) (Sem)
w
c3
(Street ) (Cityr tState) I (Zip Code)
who died on day of r 1911
at
A�\J 3
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation : 0 ?1C>y
AJV
('--g�ya-C-C- sax-f CR- - � .
(Name) (Address)
Relationship to the deceased Gy"
Name of Funeral Home .�l�11�'� /� I/�e-1��1
IMPORTANT:
r ent that to the best of my knowledge, the deceased has or
s 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
gro less, false or fraudulent.
u
c
a 2 YA
(Witness) (Address
x - - A.'C� 4 gin
(Signature of elative o/r 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
1. The crematorium will 6.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, 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
that any personal remains,
destroyed possessions have either been removed or may be
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
remains. must accompany the
4, All remains must be encased in a casket or suitable alternate
container. Casl4ets and containers must be
f combustible
material. No styrafoam or plastic containers willobe accepted.
5. The question relative to cardiac
nsweed
on the authorization to cremate form before kthe remains ers must be awillrbe
accepted.
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 t20, 00
charge for this service.
Cremation, Administration Costs and Recordin
Children (age 13 months, to 12 g Fee: Adult $ 185. 00
to 12 months) t`j0. 0Q1 Years) tl ].0. 00 Infants ( stillborn