Nelson, Robert rrO%N OF QUEEVBURY \
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 7 19� �,T'[
Name &kfi l Al.�-�ON Case # 'pL
Date of Cremation f " /'5-�—o240O
Time Cremation Started /P'6�ft_ / l l
Time Cremation Completed 13i C` P/M i
Type of Container
Remarks :
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TOWN OF QUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New Mork 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:
�n r CL a� (Sex)
(Name)
(Street ) (City) (State) (Zip Code)
0 1 , .0O O
who died on day of
at — C- 1-7
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Q alga
(Name) (Address)
Relationship to the deceased SON
�— �Fo2� lacsmr �t��C, of
Name of Funeral Home Futj ECtAL
< ,
L CEotzGe—
IPMRTANT: knowled a the deceased has or
I re esent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the regains and to direct the disposition of
ins that any personal possessions have either
the cremated remains,
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 or damages which may be made against thew by
with the cremation of said remains as
reason of or connected
ms or demands are or are not wholly
directed, whether such clai
groundless, false or fraudulent.
(Wit s ' (Address)
a?"'
(Signature of Relative or Legal Rep. an Address)
Signed on this date :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
-i-1-fo—
Other arrangements - please specify: 1 .3�L�L Q 1 Lk P
If pulverization of cremate remains is requested, check here
r; POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7 :00
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. *
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 Qf 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
'0"711ersbftalo,,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
_-__uh c i_maY_,_LDe 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
-_____..gr=md,ljqg,s,1efalse 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
-10 container. Caskets and containers must be of combustible material.
'era
Oo�lbtyt'afoam or plastic containers will be accepted.
5. Tr iuestion relative to cardiac pacemakers must be answered on
'"*'The;, ' ;horization to cremate form before the remains will be
�0 r'r
ao cerd.
b"sl'!7 Unless other arrangements are made the cremated remains will be
2R`sI, iled via Registered U.S. Mail within three days of cremation to
;r d z 9 Y
the funeral home handling the service. There will be a $20 . 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $+9-5.00
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.