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Newell, Pauline SOWN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director, 097D/ ',!L -- �, F-0(96;0�1 Name 4 G /� /�/,�C�,�.� Case # � Date of Cremation c9,dd0 i Time Cremation Started Time Cremation Completed �` /Q � /f�/� i Type of Container/IM5� 1W 16�G,(�,�' ©F Tjy,F' �/ Remarks : $ 3 I I I I I I I I 1 ..... -_....�_ ___... .,,�...rr..,.. ar.••-rcmiu.e,r►n5 VeI:�VY.NI 34EL DAM OF NO rR$ tAS72MONTNS? NO YnnES BMOeNNY S�1NU4ST NO vE3 DELIVFgV:rrMChan+ try t DOH 1 TOWN OF DUEENSBURY PINE VIEW CEWTERY a CREMATORIUM Quaker Road, ❑ueensbury, New York 12804 Phone (518) Crematorium 745-4417 or if no answer Cemetery 745--4476 C.- 4. 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: I Pauline C. Newell Fema ' (Naas) (Sex) _ Box 63 Keese Mills Road Paul Smi&hs, New Yo�l�(Street) (City) t S t ate) (-ZjWr,7CrdS who died on 21 -- day of rphrij4j�. at Moses Ludd_ ington Nursing .dome Tiean jai�6'ghan!1=-� -- (Place) (Address) Nose and address of nearest living re.1" iiv'r o �5i�`"ol tltrsnn author i x ing Cremations ;� ,;,f•t„�, .�,,_,n Donald Dlgwell (Nast) (Address) v,� rs>; , G2mr;m 1 i1A .4 Relationship to the deceased Son 1 Nast of Funeral Home Fortune-Keough Fgndr:l I WORTANT: I represent that to the best of my knowlad§Es -SPW,~-0st0 M •s Or has no pacemaker in his or her body. (Cir 19 40"! } i I certify that I have the full power and• m#!1!§a#tra to ,arrange for the cremation of the remains and to dir'eet 419 4ls004ititn Of the cremated remains, that any personal pdastsstdss #%Sve either been removed or may be destroyedg and •pee to prelecto defend and save harmless pine View Crematorium f"* awt► WW all claims and demands for loss or dam ges which may Mt 0"S against theim by reason of or connected with the cremat-ts+r of *aid remains ai directed, whether such claims or demand* 4W* 1W •re set wholly grows f Ise frau ulent. Andre* J. Fortune, Jr . ' f Y (Address) 1 - - (Wit ss .' ----GG-VV I VG VJ .G I'VRI Vt•G I,GVVYI". J18 6�1 GYLY r. 17C DISPOSITION OF CREMATED REMAINS I hereby direct Pine view Crematorium to dispose of the cremated remains as follows: Mail to 0 Church St.= 4arAna� r.atia� 'uo� Yark 129.53 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 nearist next of kin or other authorized person stating that they do bare the power and authority to arrange for the cremation of the remains and to direct the disposition of the cremated remains, that mw personal pocceacionc have either been romoved or may be dest and agree to protect, defend and save harmless Pine V ew I Crematorium from any and all claims and demands for loss of d AmKos which may be made against them by reason of or connected vitb the cremation of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are a" wholly groundless, false or fraudulent. This authorization in a mition to a regular burial permit must accompany the remains. 4. All remains must be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material. No styraioam or plastic containers will be accepted. 5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the ramsim will be accepted. 6. Unless other arrangements are made the cremated remiss will be mailed via Registered U.S. Mail within three days of czvostion to the funeral home handling the service. There will bo a $20.00 j charge for this service. Cremation, Administration Costs and Recording Feet Malt UW N � Children (age 13 months to 12 years) $115.00 Intawts (stillIM 'It to 12 months) $75 .00 * Additional $50.00 charge for cremations dire attot 3:00 Q.M. Monday through Friday. Cremations doge on iaturda" will be charged the additional $50.00. i • (signature of Relative or Legal Rep. and Address) Signed on this dace: February 22, 2000 I I