Jackson, Clifford . TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,S/(04FkJ/6
Name C-1,I JfD Case #
Date of Cremation �— oZ
Time Cremation Started 9��d A/M
Time Cremation Completed /It
Type of Container G /Z2d&Z-0 l STc
Remarks :
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TOWN OF pUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Oueensbury, 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:
Ntlanj
( e> (Sex) t
(Street ) (City) (State) (Z.ip Cod-e) .w
who died on day of e)10
at
(Place) ( ddress) = d
Name and address of nearest living relative or :- na-me, Dof
authorizing cremations
(Nave) (Address)
' -.. '1.!' f^�•l
Relationship to the decoased da4=�
Name of Funeral Home BREWER FUNERAI, HOME, INC.
IMPORTANT:
I represent that to the best of my knowledge, the decra-sped- ',ilawn or
has no pacemaker in his or her body. (Circle One),"-' ' "` 1.37F,M
I certify that I have the full power and authorizet-i-on tv,• arrag�
for the cremalion of the remains and to direct ' the' di'spos-1�1o�►, of
the cremated remains, that any personal possessions have vi .'oer
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
groundless, false or .fraudulent.
a
itn ss) (Address)
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(Signatu e, f Relative or Legal Rep. and Address)
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Signed on this date: la
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
rs 'W-w�
06tht-Y-rarrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
le tcrematorium will be open for cremations 5 days a week
#.`ii. 3:30 P. M. Monday-Friday. No Holidays or Sundays,
�a + ements can be made for Saturday. Prearrangements by
p cne---for acceptance of remains is necessary.
rrr!-'-V-i'ew Crematorium is located on the grounds of the Pine
_emetery, Quaker Road, Town of. Queensbury.
auit4i izaiion for cremation properly signed by the nearest
kin or other authorized person stating that they do have
Y and authority to arrange for the cremation of the
, ,,.T to -direct the disposition of the cremated remains,
personal possessions have either been removed or may be
and agree to protect, defend and save harmless Pine
+- :am from any and all claims and demands for loss of
L h ma-y be made against them by reason of or connected
-"'P rmab-i-o'n of said remains and/or disposition of said
r ins as directed} whether such claims or demands are, or are
jr-kvndless, false or fraudulent. This authorization
i i-4 on to,: a'f° regular burial permit must accompany the
r
04 y j ramain's , mus ,be encased in a casket or suitable alternate
"Caskets and containers must be of combustible
r _414c"ial. N. sl-yrafoam 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 $19. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $155. 00
Children (age 13 months to 12 years) $90. 00 Infants (stillborn
to 12 months) $50. 00