Rivers, Wayne t
TOWN OFQUEEVBUWy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director A-14ME-9
Name O TY'e- glv�2S Case #
' Date of Cremation ,Z'g —
Time Cremation Started
Time Cremation Completed f
Type of Container
Remarks :
TOWN OF QUEENSBURY �
PINE VIEW CEMETERY 1
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 Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) U (Sex)
(Street) (City) (State) (Z.ip; 'CodRr
who died on day of 1�-
at
(Place) (Address)
Name and address of nearest living relative or- name_,(9!,,gerson
a on ing remat i -I.t. bnz
(Name) (Address) � �.;�<-, �, i?
Relationship to the deceased
Name of Funeral Home r),7 5
IMPORTANT: �v
I represent that to the best of my knowledge,,.-the dock ltec&pas or
has no pacemaker in his or her body. (Circle Oie)
power and authorii6 on i `,*range
1 certify that I have the full
for the cremation of the remains and to direct the c.ispos . on of
the cremated remains, that any personal possessions have � ither
been removed or may be destroyed, and agree to prot. -ts -fend
and save harmless Pine View Crematorium from any and -aims
and demands for loss or damages which may be made again�.a on by
reason of or connected with the cremation of said 4946, 7s as
directed, whether such claims or demands are or are not w.iolly
groundless, 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 arrangeme - please specify:
nts check here
. If pulverization of cremate remains is requested,
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7 :00
Monday-Friday. No Holidays or Sundays,
A.M. - 3 : 30 P .M. y, Prearrangements by
arrangements can be made for Saturday.
telephone for acceptance of remains is necessary• * the Pine
2 . Pine View Crematorium is located on the grounds of
art' ---View Cemetery, Quaker Road, Town of Queensbury..
An authorization for cremation properly signed by the nearest
next of kin or other authorized stating that they do have
ied perso
the power and authority to arrange for the cremation of the remains
o direct the disposition of the cremated remains, that any
possessions have either been removed or may be destroy.
personal p defend and save harmless Pine View
and agree to protect,
-----Crematorium from any and all claims and demands for loss of damages
g
which may be made aainst them by reason of or connected with the
cremation of said remains /or ation are,00rsaid are notesins as
wholly
--directed;- whether such claims or demnds
� groundless, false or fraudulent. This authorization in addition to
permit must accompany the remains .
---a- regular burial p
r�
a casket or suitble alternate
4 . All remains must be nmust be of combusti ble material•
r container. Caskets and containers
t
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
Of ion to
mailed via ome• l threeithin y
handling the service There
h will be mat$20.00
the funeral
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.