Whitney, Marion TO(WN OF QUEEN,
15BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1
Funeral Director
� Name ) / N Case #
Date of Cremation
Time Cremation Started k2 fr 9-0 /P/M f
Time Cremation Completed �� F/ I
Type of Container
Remarks :
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TOWN OF QUEENSBURY 6Z
PINE VIEW CEMETERY
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:
(Sex) �r
(Name)
W 3 IX�✓'-" ��lGlxio
(Street) (City) (State) (Zi.p...Lbde>, cc
who died on
day of
at
(Place) (Address)
.:.:�~ bnz
g
rson
Name and address of nearest living relative or�
authorizing cremation:
(Name) (Address)
zDo
Relationship to the deceased
r :tE t�s x
Name of Funeral Home /07. a• �'`'� "`"
t
IMPORTANT: d as or
I represent that to the best of my knowledge,��the� e prj
has no pacemaker in his or her body. (Circle One)
adT , 2.
I certify that I have the full power and authorizati4,.-t��tinge
for the crmation of the remains and to direct the d: st.�,;xr"y, either
on Of
the cremateed remains, that any personal possessions hk efend
been removed or may be destroyed, and agree to prot,ec',
and save harmless Pine View Crematorium from any and al. ^laims
and demands for loss or damages
th�i�remation made
sa9dinst '�'fhea by
remains as
reason of or connected with
directed, whether such claims or demands are or are not wholly
gro%Tdless, false or fraudulent. , G
RW(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 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. *
._,.,.. ,. _„Pine View Crematorium is located on the grounds of the Pine
View,-Cemetery, Quaker Road, Town of Queensbury.
-_-____...34: ..An__authQrization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
---}»e-p w.er .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
110,2""4hd �"-aqr,ee to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss of damages
whi::h may be made against them by reason of or connected with the
=emati= -Qf. said remains and/or disposition of said remains as
directed, whether such claims or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to
..,burial, permit must accompany the remains .
.O must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
no &A! h .. :.:.
5 . The question, relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
a cF,pt '0.
3o no .p,* ,
*-+- ,less ot-ner arrangements are made the cremated remains will be
jd via Registered U.S. Mail within three days of cremation to
. xe 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 .