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Humiston, LeRoy ' L O Y V N OF QUEEMs5BU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Directorfl M2E9- Name /t d/� Case # � Date of Cremation Time Cremation Started b / f Time Cremation Completed �f �� 191Al1 Type of ContainerG��,�, /��D Remarks : �A 19M4 , I I I I I TOWN OF QUEENSHURY PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New Fork 12604 Phone (516) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematoriumt, -` in accordance with and subject to its Rules and Regulations to cremate the remains of: LEROY M. HUMISTON MALE (Name) (Sam) (Street ) f (City) (State) ( Zip Code ) who died on / � 'z 06 day of ., at (Place) (Address) X u.•,'; Name and address of nearest living relative or '­nitmez' p authorizing cremation: � J ' (Name) (Address) Relationship to the deceased J Name of Funeral Home /'! /9 IMPORTANT: F- r I represent that to the best of my knowled,ge,� thb d;icf44�d t( pacemaker in his or her body. (Circle One•)•' ^t b�� J _ased hs►sor I certify that ull power and authorization to for the cremation of the remains and to direc.t' . e"di=tip : to arrang t the cremated remains, that any personal pasta", al'ea7a -h1,4h zn been removed or may be destroyed, and agree to protect',J�t rit and save harmless Pine View Crematorium from any and all and demands for loss or damages which may be made agAinsV� T - reason of or connected with the cremation of said rimaT< 4S `�' directed, whether such claims or demands are or are not wholly" groundless, false or frauduleint. (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 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 Viewv' Cemetery, Quaker Road, Town of Queensbury. _....... _3_ ': Ate... authorization for cremation properly signed by the nearest next of kin or other authorized person stating that they do have .—.-t.he .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 "'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 ---cztio.n_ 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 . �.__._.Al.l._._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 j :he authorization to cremate form before the remains will be :e�ted.. s �. . - • - . U.nleas, other. arrangements are made the cremated remains will be . .Ailiec:- 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 .