Thomas, Doris Win. _.........
TOWN OF QUEEN4.5BU ly
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
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TOWN OF GUEENSBURY
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 Cremator ons toium, in
accordance with and subject to its Rules and Regulati
cremate the remains of:
Fina,U
(Name)
(Sex)
S t cm W ea.— /U e, 22 arrv� v N
(Street)
(City) (State) (Zip Code)
who died on
221ud d a y of Nave 1929
AM-
at Ind,�an "ZLveet ehab�rt c flea.CtA renteAg
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
_ David l3. TlwmcrI G274 N _ {� e C raV L-- Lantana, FL 33�
(Name) (Address)
Relationship to the deceased _502
Name of Funeral Home &d an. Funew� flame, Faint flan. N! l2427
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my 9
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
defend
either
been removed or may be destroyed, agree
and save harmless Pine View Crematorium from any an all
ltclaims
and demands for loss or damages which may be made against
reason m by
of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent. .
. P,0, l30x 277, Fit. fly4 NY, 1282Z7
(Wit n s s) , (Ad a�eA� ,Nero P/wvt deace 2d,
(Signature
of Relive or Legal Rep. and Address)
Signed on this date: Nav, 22, 1999
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the4crbteated
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
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 Children (age 13 months to 12 years) f11,0. 00 Infants ( stillborn
to 12 months) f70. 00