Calcagne, Lillian r'_O WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S M6/ OX 12
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Name h I k�( C'&�- JVoc Case #
e
Date of Cremation
Time Cremation Started �,� J9 �Jl� 1
Time Cremation Completed
Type of Container
Remarks :
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 sub*cats
to its Rules and egulations to cremate the remains of:
C,#Z P;�,
(NAME) ( )
(STREET) (CITY) (STATE) (Zle tOD4)
who died on c.� day of
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at i/i1�`�!v
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing;crernation7 s W cci 9 rl I
urr: Iysb
Relationship to deceased 0 lr'i h �Xi?-'�� n Z aii d :r—r�- - g 1 v
T y o��,j.y �j
J -J t'.1 t;� J7 iJ del l W ,(
Name of Funeral Home
t t s h b,s n t
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no'paddiinbk'r in'hiss 6Pber •�'
body. (CIRCLE ONE)
is ram;,3�,ai
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 eithef1been
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 n t whplly groundless, false or fraudulent.
T�
ITNE ' (AD E S) >
l
SIGNATURE OF RELATIVE OR LEG REP. AND ADDRESS)
Signed on this date: / v
9 (/
DISPOSITION OF CREMATED REMAINS
hereby direct Pine Vi Crematonumjg7dispose of the cremated remains as follows:
Mail to
--Other arrangements-please specify:
If pulverization of cremated 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
------}�ersorrstating 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
------I armtess 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 and/or disposition of said remains as directed, whether such claims or demands are,
----orare-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. Caskets and
per,.;o ,iGontliners must be of.combustible material. No Styrofoam or plastic containers will be
accepted:
bpslr,,The,questiom relative to cardiac pacemakers must be answered on the authorization to
nC,, ,,., ,_cremate form before the remains will be accepted.
6- Unless other arrangements are made the cremated remains will be mailed via Registered
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.