Bain, Gustave L O`Y 4N OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funerals DirectoriC yl,,1141 cg eS7 ,
Name �C�S'TJ'}�,E� j� �/� Case # �
Date of Cremation
Time Cremation Started
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Time Cremation Completed 4 r L
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TOWN OF QUEENSBURY
• PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
Gustave Bain Male
(NAME) (SEX)
22 Rock Street Greenwich New York 12834 '
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 9th day of February 2000
at Glens Falls Hospital Park St Glens Falls; NY!,
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation::'
Rachel Swiss 00883 Clute Road Boyne City, MI 49712• `
Relationship to deceased Daughter
Flynn Bros. , Inc. - Gree.nw;ich f ;jNy-j:F06.
Name of Funeral Home
..:T 7 ...
-,
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has rno kemaker"in his or her
body. (CIRCLE ONE) r.
I certify that I have the full power and authorization to arrange,for the c ematto'n'of th`e7emair�s and
,.
to direct the disposition of the cremated remains, that any personal possessions haveIdither 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
ch claiLNS
not wholly groundless, false or fraudulent.
80 Main Street Greenwich, NY 12834
(ADDRESS)
r U-- 00883 Clute Rd Boyne City, MI 49712
( IGNATURE OF ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: Feb. 20. 2000
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: Will Pick Up
If pulverization of cremated remains is requested, check here XX
-�~ - 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-
'vFriday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements
'bytelephane for acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
-- —'Townyof Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
persan.statjng 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
_-- `tMrn'ttewPine 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 and/or disposition of said remains as directed, whether such claims or demands are,
or Fi hbTGVtToHy groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
` . -Att remaing' Susi-tie-encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
red G qu.gst4v,,n,relatjve-to cardiac pacemakers must be answered on the authorization to
cremate form before-the remains will be accepted.
b„_ ,,���ntess other arrangements are made the cremated remains will be mailed via Registered
n U.S. Mail within three days of cremation to the funeral home handling the service. There will
be a $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 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.