Toomey, Vincent rrO q+N OF QUEEM5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I
Name if'lCF/vr Case # lj
Date of Cremation
Time Cremation Started -1/3<1 /L--/7m I
Time Cremation Completed 3 t" jP/
Type of Container�9��r0�
Remarks :
02 i3� /�i/►� r
TORN OF GIUEENSBURY
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
cremate the remains of:
Vi nr_an t P_ Tpnminy m
(Name) (Sex)
1132 Perth Rd. Hagerman NY 12086
(Street ) (City) (State) (Zip Code)
who died on 16 day of October 19 2000
at At Home 1132 Perth Rd. HaQaman, NY 12086
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Steve Ercole 1132 Perth Rd. Hagaman, NY 190RC,
(Name) (Address)
Relationship to the deceased Friend
Name of Funeral Home Tunison Funeral _Home
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
ou dles , false or fraudulent.
(Witness) (Addr ss)
9 &gj
'6 -AA4 X1 Sao
(Signature of Relat ve or Leg 1 Ffep. and Address) Vti'
Signed on this date : (/
N
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
1. The crematorium will be open for cremations 5 days- a week
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
-----rae:et 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,
"tFat 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
----d�m,ages wh"ich 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
^at--wholly groundless, false or fraudulent. This authorization
in addition to a regular burial permit must accompany the
4. All remains must be encased in a casket or suitable alternate
7oc"n-ta'inew. ' Caskets and containers must be of combustible
material. No st'yrafoam or plastic containers will be accepted.
9p5i The question relative to cardiac pacemakers must be answered
loo the authorization to cremate form before the remains will be
a.-a^cept ed.
r.
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 $185. 00
Children (age 13 months to 12 years) $ 11.0. 00 Infants ( stillborn
to 12 months) $70. 00