Owens, John rIOq+N OF QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Z -
Name �JG&i Case # QZQ
Date of Crematicn-6-*,- '7 i / /
Time Cremation Started
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Time Cremation Completed 5t /l I-1r1 -
Type of Container
Remarks :
Aizi i IN 0GV//A4G-9 oaf v/, A
110
TOWN OF QUEENSDURY
PINE VIEW CEMETERY
at
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:
UO,
(Name) (Sem
GVV�>
_It �' N q -7 C,C) I
(Street ) (City) (State) (Zip Code)
who died on l day of 19
at S S
(Place) (Addr ss)
Name and address of nearest living relative or name of person
authorizing cremation :
nu_-)eANA
(Name) (Address)
Relationship to the deceased Srdb&Z')
Name of Funeral HomeC'li�\
IMPORTANT:
I rep at to the best of my knowledge, the deceased has or
has no pacemak_eO 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 clai-ms or demands are or are not wholly
o ndless, alse or fraudulent. cc
(Witne ) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date :
1
L1g7 y
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.
arrangements can be made for5atday.No Holidays or Sundays,
telephone for acceptance of remains is necessaryearrangements by
2. Pine View Crematorium is located- on the grounds of the Pine
View Cemetery, Quaker' Road, Town of Queensbury.
3. An authorization for cremation
next of kin or other, authorized Properly signed by the nearest
the person stating that they do have
Power and authority to arrange for the cremation remains and to direct the disposition of of the the cremated remains,
that any personal possessions have either been removed or may be
destroyed and agree to protect,
View Crematoriumdefend and save harmless Pine
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.
in addition to a regular burial This authorization
remains. permit must accompany the
4. All remains must be encased in a cagl4et or suitable alters,ate
curitainer. Casi�ets and
material. containers must be of combustible
No styrafoam or plastic containers will f accepted,
5. The question relative to cardiac
on the authorization to on must be answered
accepted. cremate form before the remains will be
b. 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
charge for this service, the service. There will be a s20. 00
Cremation, Administration Costs and Recordin
Children (age 13 mont•'hs to 12 9 Fee : Adult $ 185. 00
to 12 months) s70. 00 Years) si ],0. 00 Infants ( stillborn