Chase, Jesse Jr. L. rrnq4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ��z. clJ� /lam Q Rt Case # p2�
Date of Cremation Z-- 161 — go<0Q'j
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Time Cremation Started ��� /M T
Time Cremation Completed �� ��Al �
Type of Container
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TOWN OF l3iJEENSBURY
PINE VIEW CEMETERY
:m
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 auin
thorizes Pine hand Reeulationsatorium' to
accordance with and subject to its Rules 9 `
cremate the remains of:
Ss C (Se
K)e
(Name)
Saratoga Springs, NY 1286Fj_3,:v F':_ -
24 Clark St. , (state) ('Zip=0adw�J weir'
(Street ) (City)
-13- - 7I �'W_E
January
16th day of
who died on U iC) tli::d ?C X9.I
Saratoga Spri;--- ; -
at Sarato a Hos i tal, Church St. ,
(Place) (Address) a.3a3Jq C;Lreaasq
of nearest living relativeJ-orq nA4* a)fbz�r*". s
Name and address
authorizing cremations < <;s 3: Zx : i 1r:a;r: cl `a 66
46 Dyer Switch Rd. , SA`.a't0 b8pringf-,Yj
Jon Swick, J�fa �e:r1 ......
(Name) (Address)
Relationship
to the deceased Son
William J . Burke' & 9bnSaB1an@99j.Rg4e!piA L
Name of Funeral Home ti F ?f10'J
OPI
IP1PORTANTs knowledge, the deceased has or
1 represent that to the best of my teiri•D+ Onar '; 9AT . 2
3
has no pacemaker in hi's or her body• 7, ._ r;C)
I that I have the full power and authorizat
certify ion ' 'fi59e
for the cremation of the reman of
ins ansen`al�.i={3ossessiDJt.sshaveteoithcjr
that any Per
the cremated remains, acid a se.. :tQ prat,ect, .,4s,fbe +d 1
be destroyed, '_ 9�'"
been removed or may and all .ck, s
and save harmless Pine View Crema►toriva� fz"o.m as►X �
remains as
and demands for loss or dWmtheSthe which
cremation mofesa9dinst. t :�-�, of
reason of or connected
directed, whether such claims or demands are or are not wholly
fal -"" audulent.
roundless, � p
S rings, NY
628 N. Broadway, Saratoga
/ A tAddress)
(With ss) `
el 1Sh �v
(Signs re of
Relative or Legal Rep. and A dress)
Jan. 17 , 2000
Sign on this dates
7 .w
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 hare
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 ,
,�&Tfgements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
-'Vi w-Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queens]Dury.
l
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the power an-a"'authority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains , that any
+pegatpnal,n pgasess,ions hqLve 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 mSL 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
soundless, false or fraudulent. This authorization in addition to
a regular burial "permit" must accompany the remains .
4.All"'rema ns"-musb `be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material .
-•aNesatyra,fQan or plastic ,containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
9 9tkv!-q Qatthorizat ion to cremate form before the remains will be
't o atm.-ept.ad.
bmflt> Unless othar arrangements are made the cremated remains will be
"*fdiied via Registered U.S. Mail within three days of cremation to
V"`taa 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
;' ''NQCkts dbvW . 00 charge for cremations done after 3 :00 P .M.
Monday througf Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .