Gaillardet, Marie rrO q+N OF QUEEVBUr�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name,M&Y/) 6y-)n/'a 1 19)(n,O Z: Case # f
Date of Cremation /—Sf —
Time Cremation Started ice /
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Time Cremation Completed I' Vk� /Il (' l} �
Type of Containery
Remarks : `
��A NI1
TOWN OF QUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12B04
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:
Mwrm'e_ fl J
(Name) (Sex)
dim
(Street) (City) (S •ate) (rip Code) ,
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who died onay of /b
at (�l2--is � bg-/Z
(Place) (Address)
a�i-e of person
Name and address of nearest living relative' or J nyr
authorizing cremation: ,, 4
4#16PAJ 6ai114 �.
(Name) (Address) �..., e sL)
Relationship to the deceased
Name of Funeral Howe
IMPORTANT:
I represent that to the best of my knowledg0, 'ifte aic..
has no pacemaker in his or her body. (Circle Orlfrs �'�
I certify that 1 have the full power and "ary4Ahoi-'•izat1on ,
for the cremation of the remains, and to di�ecdtV`t�ir dis'
the cremated remains, that any personal' po' °�s4_4%4ibbs
been removed or may be destroyed, and agree to pro-L','% , t
and save harmless Pine View Crematorium roo 'any Ad a = '' •- 'i ,•
and demands for loss or damages which may be made agains.. hew cy
reason of or connected with the cremation of said remains as
directed, whether such claims or de�sands are or are not wholly
gro d e , fa e,_.or fraudulen
�li�l'G6h L�V.R.
fitness (Address)
io
(Signature of Relative or Legal Rep. and Address)
Signed on this date: G� f
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail_ to Vyi 1) � Uf—
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
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POLICIES, RULES AND REGULATIONS
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
teLaphone for acceptance of remains is necessary. *
2 . Pine View Crematorium is located on the grounds of the Pine
!'� -V Cemetery, Quaker Road, Town of Queensbury.
Pf -3--.-- An'-authorization for cremation properly signed by the nearest
s4 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
dir-ec-ed, whether such claims or demands are, or are not wholly
Zroundless, false or fraudulent. This authorization in addition to
-agular burial permit must accompany the remains .
k
,t ,remaihs must be encased in a casket or suitable alternate
her. Caskets and containers must be of combustible material.
v afoam or plastic containers will be accepted.
iestion relative to cardiac pacemakers must be answered on
-i%v:ion to cremate form before the remains will be
s r�
s A other arrangements are made the cremated remains will be
via Registered U. S. Mail within three days of cremation to
. he 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.