Nasen, Janet TO q+N OF QUEEM,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directors/1 P5-5�
Name C lVL7— Case # J12
� I
Date of Crematicn
I
Time Cremation Started_ < �� / / �(�' ►
I
c�f
Time Cremation Completed
Type of Container
Remarks :
AM/1-4 90/r AGW Dist b�✓�� /�iM
i
7,-13
IL
i
i
it
i
I
i
it
OF allEENSBURY l�
TOWN 6
pIW VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 774-44776or if no answer
Cemetery
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View and Regulations to
in
accordance with and subject to its Rules
cremate the remains of:
Janet Naze2 Temaie
(72z. a (Sam)
(Name)
fait Maven, Ve2mont 05743
124 North (7a-.n StlLeet (State) (Zip Code)
(Street ) (City)
Z3ad day of June — 1g99
who died on
at Rutiand Re ionaj Nedicaj C
Eme2 enc /loom
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation: �
124 No2.th Ma-in St. , fa.�2 Raven, Vt.-
Rev. Co2don Nazez
(Name) (Address)
Kaz and
Relationship to the deceased
Name of Funeral Home
[7a z&e T uae2ai Home
i
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that 1 have the full power and authorization to arrange
for the cremation of the remains �rsonal direct
possessions disposition
either
the cremated remains, that any p
be destroyed, and agree to protect, defend
been removed or may
and save harmless Pine View Crematorium from any and all claims
st them by
and demands for loss or damages which may
be made
e said inremains as
netted with the cremation
reason of or con are or are not wholly
directed, whether such claims or demands
groundless, false or fraudulent.
i
(Witness) ,(Address)
(Signatur of Relative or Legal Rep. and Address)
signed on this dates lung 24 1999
Sig �
i
II�
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium ', to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify: Sj, aE
If pulverization of cremate remains is reque ted, eck here�-
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cre ations 5 days a week 7 : 00
A.M. - 3 : 30 P.M. Monday-Friday. o Holidays or Sundays,
arrangements can be made for Satur ay. Prearrangements by
telephone for acceptance of remains is ecessary. *
2 . Pine View Crematorium is located o the grounds of the Pine
View Cemetery, Quaker Road, Town of Qu �nsbury.
3 . An authorization for cremation prop rly signed by the nearest
next of kin or other authorized person tating that they do have
the power and authority to arrange for th cremation of the remains
and to direct the disposition of the c emated remains, that any
personal possessions have either been re oved or may be destroyed
and agree to protect, defend and s ve harmless Pine View
Crematorium from any and all claims and d mands for loss of damages
which may be made against them by reason of or connected with the
cremation of said remains and/or dispos tion of said remains as
diregted, whether such claims or demand are, or are not wholly
groundless, false or fraudulent. This aut orization in addition to
a regular burial permit must accompany t e 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 b accepted.
5 . The question relative to cardiac pacem kers must be answered on
the authorization to cremate form befo a the remains will be
accepted.
6. Unless other arrangements are made the remated remains will be
mailed via Registered U.S. Mail within th ee 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 .0 Infants (stillborn to
12 months) $75 .00
i
* Additional $50 . 00 charge for cremation done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 .00 .