Williams, Frank TOWN of QUEEM4,5BWU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��� /►
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TOWN OF allEENSOURY
pINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New Yor 12804no answer
Phone (518) Crematorium 774544776or if
Cemetery
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium,
to
in
accordance with and subject to its RulesRegulations
cremate the remains of:
cam` (Sex)
(Name)
(City) (State) (Zip Code)
(Street )
19
who died on
+� d a y of
at
(Place) (Address)
lative or name of person
Name and ad
dress of nearest living re �
authorizing cremation:
X (Address)
ame)
Relationship to the deceased
Name of Funeral Home r, 7
IMPORTANT: knowledge, the deceased has or
I rear_ at to the best of my 9 '
has o pacemaker -in his or her body. (Circle One)
I certify
that i have the full power and authorization to arranne
n Of
for the cremation of the remains ato dipossessionsrect the shave(either
the cremated remains, that any personal
be ma des defend
destroyed, and agree to protect,
been removed or Y any and
ms
and save harmless Pine
nor View damages whichbemmade against l them by
and demands for loss
reason of or connected with the cremationands re°arsaare not awholly
directed, whether such claims or de
groundless, false or fraudulent.
i
(Witness) (Address)
(Signature of Relativeand Address)
or Legal Rep. l
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 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 form before the remains will be
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 $20.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 . 00
Children (age 13 months to 12 years) $115 . 00 Infants (stillborn to
12 months ) $75 . 00
* Additional $50 . 00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 .00.