Bradshaw, Ruth . rrnqlN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / 1,8, �AtC I
Name A 12 &!/ 51#4j Case #
Date of Cremation /" d— aC` 16
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Time Cremation Started ,c� r �b f"M !
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Time Cremation Completed cZ 1 n"M
Type of Container G/'gJF25bA.70
Remarks :
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• TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
Ruth C. Bradshaw Femal•a _
(Sex)
(Name)
uihlsin Marcy Center Lake Placid, NY
(Street) (City) (State) (dip Cold* �
%'�tj ! eJ W91v
who died on 15;th day of Januar 192000-
-o::� �s rIA . E
atfiihl�in Marcy Cantar, 429 Old Military Rd . , EL'4 ih) 449;2946
(Place) (Address) "f,.' a5WOL ett.
arb o�J bns
Name and address of nearest living relative o1r n p 6ri Qjn
authorizing cremation:
: e s=pL bnz
�' (�—/I i i fi }i v T KT tr -L 3 ,9 '? l rf W
irct > =nIS7J
(Name) (Address) �... ".. .. _ rc97 ib
Relationship to the deceased Snn
Name of Funeral Home M B Clark, inc. , 27 Saranac Ave. .
IMPORTANT: -1
I represent that to the best of my knowieige-i�-,th**" doc 41isiTdhklao%or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization .to . ar *ridge
for the cremation of the rem
sins and to direct the dispositlaxBof
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protects defand
and save harmless Pine View Crematorium from any and al.l C sy ms
and demands for loss or damages which may be made against thoa-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.
I
27 Saranac . via. T ka rlaci�3 N 12946
Witness) 780IS- lu-
dress)
2�2d
5 T( ( 1
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 1/�� /
ti
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to M. B. Clark, Inc. , 27 Saranac Av2,m Lake Placid, NY
12946
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
View Cemetery, Quaker Road, Town of Queensbury.
3 . An authorization for cremation properly signed by the nearest
next'-6f'--kin or other authorized person stating that they do have
the power and authority to arrange for the cremation of the remains
a ;-1;R cUrect 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"-fie "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
gro1fn3l-ess;- false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable alternate
cg �pe�;.•;;x;Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
5- he question relative to cardiac pacemakers must be answered on
t . authorization to cremate form before the remains will be
& eepted.
6. Unless other arrangements are made the cremated remains will be
V.
mailed 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 thid 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.