White, Geneva T01+N OF QUEEN,,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectordTE��
Name� /�,�lJlil 724-- Case # l
Date of Cremation Z—Al ^ ;9-�
Time Cremation Started/I, P/A4 '
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Time Cremation Completed cq-�f (96 A lY �
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TOWN OF QUEENSOURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Glueensbury, 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 v�of:
p
(Name) (Sex)
(Street ) (City) d ( tat Vtip Code)
who died on _7 day of
at
(Place)(J (Address)
Name and address of nearest living relative or name of per,on
authorizing cremation:
(Name) (Address) 61
_
Relationship to the decpased /1J
Name of Funeral Home
BREWER FUNERAI, HOME, INC.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization 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, 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 them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or - are not wholly
ground ss, false or fraudulent.
(Witness) (Address) �-
(Signature of Relative or Legal Rep. and Address)
Signed on this date: l / 7 1:29000
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.
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, of 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 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 be made against them by reason of or connected
I with the cremation of 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 a regular burial permit must accompany the
remains.
4. All remains must.- be encased in a casket or suitable alternate
container. 60skets and containers must be of combustible
material. K: s4yrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered
on the authoriz ion to cremate form before the remains will be
accepted.
3
6. Unless 4th . arrangements are made the cremated remains will
be mailed vik'" Registered U. S. Mail within three days of cremation
to the fuser l home handling the service. There will be a $19. 00
charge for 4his service.
Cremation, Administration Costs and Recording Fee: Adult $155. 00
Children (age 13 months to 12 years) :90. 00 Infants (stillborn
to 12 months) $50. 00