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Dever, George Jr. TowN OF QUEEN.,5Bw1Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �`� Name � y/S�Y,� — Case # oc IA:) Date of Crematicn 10/ / 9 / Time Cremation Started/ ge / / tm 1 Time Cremation Completed 1©., '?`,5— ,110 "7� Type of Container 10 S/%J T �- Z59 / r Remarks : /1 fi2�33 TO{iW'-OF� QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road,. Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cei atvey 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and 'authdrizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to crelpato the remains f: (Na ,v (S K) (Street) . (city) (State) (Zip Code) who ied on day. of 19� at 1 (Place) (Address) Name and address ,,.of nearest living relative or name of person author. zing cre tion: 0o``11 (Name) ,::. (Address). Relationship to the deceased Name of Funeral Home IMPORTANT: I ent -that o t best of l:y knowledge, the deceased has or as no pacemaker ' n is or her body. (Circle One) I certify that I have the full powier and authorization to arrange for the cremation of the remains and to direct the disposition of the cremated remains,_ rxhat any personal possessions have either been removed or may ..bi'`"destroyed, 14and agree to protect, defend and save harmless Pink View Crematorium from any and all claims and demands for loss"�or­damages 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 ' cr­fra'"if lent. 44itnes ) tAdd ss) (Signature of Relative 7�9(? @gal Rep. and. Address) Signed on this dates 6 DISPOSITION., OF. CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements - p ease 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 to­arrange 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 made4the 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.