McCormick, Ellen TOWN OF QUEEN
,5BUP.,y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 0a L SC Al
Name OC CorM Ck Case # =T�
Dat e of Cremat i cn / 0—// ` /
Time Cremation Started ' D P- in
Time Cremation Completed I " 55 P. m 4
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Remarks :
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TOWN OF pUEENSBURY
PINE VIEW CEMETERY
14
CREMATORIUM
Quaker Road, Queensbury, New York 128e4
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
to its Rules and Regulations to
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject
cremate the remains of:
Ellen C. Mc Cormick Female
(Sex)
(Name)
Mid 1p Code)
103 (City) (State
(Street ) 19 99
who died on
16 day of
oc
Saratoga
Sarato a H ' 2
at (Address)
(Place)
Name and address of nearest living relative or name of person
authorizing cremation:
103 Sto 50
Francis (Address)
(Name)
Relationship to the deceased
Husband
Name of Funeral Home
William ome
IWORTANTs knowledge, the deceased has or
I represent that to the orsherf body. (Circle One)
has no pacemaker in his
I certify
that I have the full power and authorization to arrange
end nal possessions have either
the cremation of the remains and to direct the disposition
Of
for that any P rotect, de
the cremated remainsbe destroyed, and agree" to p
been removed or may View Crematorium from any and all claims
and save harmless Pine es which may be made against thew by
and demands for loss or dama9 the crIN b"Q1nBud& &4;W3
remains as
reason of or connected with dgOAR bloithsBroadware not wholly
ed, whether such claims or SaratogaSprings,NowYork12666
dir
ound ess, fall or f audulent. (518) 584-5373
(Address)
Witnes �+
214 Jones Rd, SS N
l Rep. and Address)
(Signature of Relative or Lega
Octobe
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 pick up
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here_.&XX
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.