Sperling, Colleta TOWN OF QUEEN,5BU9Zy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director X j y`, C( JUI'Alls:,
Name r..JQ )I�Tz 5-�� )� Case # D
Date of Cremation
Time Cremation Started //Y
Time Cremation Completed ��� fKIN
Type of Container o � , O
Remarks :
Al �
TOWN OF QUEENSBURY I/ -
PINE VIEW CEMETERY
a
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
cremna the remains of:
r,�Q a i� M S U'� -�-CA-k
(N me) I SSex)
QUA L&"�� Vga�je
ACC
(Street ) (City) (St
`atte) (Zilo C de)
who died on day of ��(�( 19q
at
(Place) ( ddres )
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Ad ess)
Relationship to the deceased
0 L4�k
Name of Funeral Home L C
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no 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
o ndle , I or fraudulent.
t 'tnes (Address)
ignature of Re t ve or Le 1 Rep. and Address)
fgned on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pi
ne View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrang
ements - please specify: check here _
If pulverization of cremate remains is requested,
POLICIES, RULES AND REGULATIONS
en for cremations 5 days a week 7 :00
1 . The crematorium W1Monda l be oFriday. No Holp earrangements Sundays,
bY
A.M. - 3 : 30 P .an Y Saturday.
arrangements can be made for
remains is necessary. *
telephone for acceptance of rem
ounds of the Pine
2 . View Crematorium is located on the gr
V Pineiew Cemetery, Quaker Road, Town of Queensbury.
V
ro erly signed by the nearest
3 . An authorization for cremation =Son stating that they do have
next of kin or other authorized for the cremation of the that any
the power and authority to arrange
and to direct the disposition erf the cremated remains ,
been removed or may be destroyed
y View
personal possessions have either
agree to protect, defend and save harmless Pine
and and all claims and demands for loss of damages
Crematorium from any reason of or connected with the
which may be made against them by osition of said remains as
cremation whether such lcla msns /or demor ands are, or are not wholly
directed,
roundless , false or fraudulent. This
ache remains . in addition o
g permit must accompany
a regular burial p
a casket or suitble alternate
4 . All remains must be encased nmust be of combusti ble material-
container. Caskets and containersNo styrafoam or plastic containers will be accepted.
ed on
5 . The question relative to card crm pbeforeacemake rs then st be remains answerwill be
the authorization to cremate f
accepted. mated
6. Unless other arrangements reil made the three- days f maremation ins will to
mailed via Registered U.
S.the funeral home handling the service. There will be a $20.00
charge for this service.
Cremation, Administration Costs and Recording Fee. xcl-14 4189 _ee
Children (age 13 months to 12 years) $115 .00 Infants (stillborn to
12 months) $75 .00
M.
* Additional r h$50 -00 Friday.charge Cremations done cremations onne after Saturdays3:0 will.P.be
Monday through
charged the additional $50.00 .