Clough, Gerald rrn"NN of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M6r,LaL q Ni
Name � � �„' t'l l.� �,bfJ V�1 Case #
Date of Cremation 11 — q
Time Cremation Started tl
Time Cremation Completed 1 D LOB,
Type of Container ct'b'
Remarks :
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TOWN OF UUEENSDURY
PINE VIEW CEMETERY
as
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) 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 t remains of :
CIO 4 l tit
(Street ) ,/ (City) (State) ( Zip Code)
who died on ��� day of ��eCGiKOCiQ 19 44
c ,�J
a t
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
� 171,16er 2f. aT
(Name) (Address)
Relationship to the deceased/
Name of Funeral Nome Nr
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
gro ndless, false or fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date : �,
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
POLICIESI RULES AND REGULATIONS
1• The crematorium wi l l b,e open for
7:00 A. M. 3: Monday-Friday.
cr•emat.lons 5 days• a week
- 30 P. M. Monda
y Friday a. Noy. Holidays or Sundays,
arrangements can be made
telephone for acceptance of remains is necessaryearrangements by
2. Pine View Crematorium is located- on the grounds of the View Cemetery, Quaker• Road, Town of Queensbury. pine
3• An authorization for cremation properly next of {yin or other, authorized signed by the nearest
the power and authorityPerson stating that they do have
remains and to direct the tdisposition range fof the cremated or the nofte
that any personal possessions have either beeh removed or may be
destroyed and agree to remains,
nd and save
View Crematorium from any and allcladefems and den�ands,aforelossine
damages which of
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.
in addition to a This authorization
remains.
1^egular burial permit must accompany the
c• All remains must hs• encaseci in a casScet or suitable alternate
container. Caskets and
material. Na styrafoam or c°ntainer-s must be of combustible
plastic containers will be accepted.
5• The question relative to cardiac
on the authorization to Pacemakers must be answered
accepted. cremate form before the remains will be
6• Unless other arrangements are made the cremate
be mailed -via Registered U. S. Mail within three days of ainscremation
to the funeral home h d remains will
charge for this servicpoling the service. There will be a t2000
Cremation, Administration Costs and Recording
Children (age 13 months to 1.? Fee: Adult $ 185. 00
to 12 months) s7O. 00 Years) = 1 ],0. 00 Infants ( stillborn