Brundige, Dorothy ,;9,'.tzi...1='r'
TOWN
QUEEM4,5BU9U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director,✓/zj/1
Name �/ �1��//� Case # ^
Date of Cremation y� �
Time Cremation Started �f ! -
Time Cremation Completed/ t 5;7' // jkj r
Type of Container l9
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
aG
CREMATORIUM
Quaker Road, Queensbury, New York 12BO4
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATEin
iew Crematoriu
The undersigned requests and au andVand Regulation] to
accordance with and subject to it
cremate the remains of:
i
Dorothy W. Brundie Female --
(Sex)
(Name)
r---- I
18 Cl ( ity (S a eS ip Code
(Street )
May
99
4 day of ! _
who died on
at Sarato a figs it
211 Church
4 �-"
(place) (Address)
' in relative or name of i person
Name and address of nearest living
authorizing cremation:
SS, NJ, 12866 ,...�_
Susan Brun �
(Name) (Address)
Relationship to the deceased
Daughter
Name of Funeral Home
wm. J. Burke & Sons Funeral Hone
I
IMPORTANT' knowledge, the deceasli has or
1 represent that to the best of my (Circle One)
has no pacemaker in his or her body.
ion
ge
I certify that onhofethee full remainsower and toddirectrthetdispollitionnOf j
for the crematio that any personal possessions haile either
the cremated remains, and agree to protect, defend
been removed or may be destroyed, 9
and save harmless Pine View Crematorium from any and Il claims
may be
t them by
or
and demands for lonecteddwitheSthelch cremation mofe in said mains as
reason of or con
uch claims or demands are or are t wholly
directed, whether s
groundless, fall
or fraudulent. �
ii 2 i �
(Witness) (Address)
j'
(Signature of
Rela ti a or Legal Rep. and Address)
Signed on this date: _
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Burke FH. will Pick up
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here xxxxx
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. I
t0l IAA ;h Friday. Cremations done on Saturdays will be
$ ' 1 50 ,00
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