Wallace, Claire TOWN OF QUEENs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /ya/vh�
Name 0k/1/9' Zj/'l� Case #
Date of Cremation 2 'n - �-'r r,4
Time Cremation Started ��-i,7 l
Time Cremation Completed
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TOWN OF allEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12B04
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
w Crematorium, in
The undersigned requests and suo°1tseS Pine Rules Vie
and Regulations to
accordance with and subject
cremate the remains of:
Claire (Sex)
(Naga)
Sarato ' NY
76 Ta (State) (Zip Code)
(city)
(Street ) 19 99
day of October
who died on 23
SS
Sarato a 211
at (Aae�iress)
(Place)
Nag
e and address of nearest living relative or Wage of person
authorizing cremation:
Vaughn C. Gorh 76 T Tra '
(Name) (Address)
Relationship to the deceased
Daughter
Name of Funeral Hoge
Wm. J. B me
IMPORTANT: knowledge, the deceased has or
I represent that to the best rA my (Circle One)
has no pacemaker �,---
o her body.
I certify
that 1 have the full power and authorization to arrange
to
rect the
ion Of
for the cremation of the rel�an^span onaldipossessionsshaveteitherr
the cremated remai^sbethdestroyed, and agree to protect, defend
been removed or may View Crematorium from any and all claims
and save harmless Pine whiI:h may be made against them by
and demands for loss or damages remains as
reason
of or connected with the cremation of said wholly
directed, whether such claims or demanWill am J°Burke& Sons
groundless, false or fraudulent. 628 North Broadway
Saratoga Springs,New York 12866
(Witness)
Legal Rep. and Address)
(Signature of Relative or Lag P
Signed on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Burke Funeral Home will _; r•k lip
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here xxx
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.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 .00.