West, Edith 70 WN OF QUEENs5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 96 N
Name F10) T-/7 zjz-sr Case # �• �3
Date of Cremation
Time Cremation Started ZZ/ A rM f
Time Cremation Completed /01 , 4C �Mt
Type of Container zfh ygE X w a/yy" C / 52�-
Remarks : ^ ;
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TOWN OF QUEENSBURY
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:
d iA IfJ West Fena. e
(Name) (Sex) .3 .._
40 r. au #j U U, Font Ann. Neu Y(2Ah -
(Street ) (City) (State) (Z-Ap. Co4gli .
who died on
/2A day of Y 2WO
at i. vw Fa,CCd #Odpi. F"
(Place) (Address) a-.. c, bnz
Name and address of nearest living relative or n.ar,IC-of bMrsOy
authorizing cremation: rn10
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I?ona,(d Wed 44 fli.GC
(Name)
(Address)
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Relationship to the deceased .Son
Name of Funeral Home
Marlon Fwtew-l- floor Font
IMPORTANT: 0 �
sent that to the best of my knowledge, the decaased't,#16 or
has no pacemaker in his or her body. (Circle--pnt) "
,jm a
4 ; 9ri.;
I certify that I have the full power and authorization t�� r'ange
for the cremation of the remains and to direct the dispcvietiither
personal posscasions Of
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the cremated remain s, that any p . ..
been removed or may be destroyed, and agree to Prot ect SJefend
and save harmless Pine Via w CreWhichimayum f bemmade against any and realms
and demands for loss or damages
es 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.
' Hess)
(Addres )
F
(Signature of Relative or Legal Rep. and Address)
JanSigned on this date:_,_-/j�a
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. *
View Crematorium is located on the grounds of the Pine
View' Cemetery, Quaker Road, Town of Queensbury.
"M 3 . "Alt"^,authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
-----T d''p- wer,"and authority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains, that any
r o ossessions have either been removed or may be destroyed
��� � ���rP Y
and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss of damages
hich may be made against them by reason of or connected with the
M f&tt='-af' said- remains and/or disposition of said remains as
ti icted, whether such claims or demands are, or are not wholly
` 'idless, false or fraudulent. This authorization in addition to
uta-r-bursa3--permit must accompany the remains .
ml 'remains must be encased in a casket or suitable alternate
ier. Caskets and containers must be of combustible material.
_ � .,afoam or _plastic containers will be accepted.
cz
uestion relative to cardiac pacemakers must be answered on
1„ :ization to cremate form before the remains will be
o nf'd t ed.
bnq' 5. zless other arrangements are made the cremated remains will be
tariled via Registered U.S. Mail within three days of cremation to
• :' the fuaneral home handling the service. There will be a $20.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $19 0
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.