Wood, Wesley TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 5*1 /V) t 0(1)
Name 066 Z2 Case #
Date of Cremation
Time Cremation Started
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Time Cremation Completed 1r �fJ`- Ni �
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TOWN OF UUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTNORItRTION TO CREMATE
The undersigned requests and authorize! pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft
S ood
(Sam)
(Name)
ao
(Street ) (City) (state) ( Zip Code)
who died on
< d s y o f /.��. oG►
at
(place) (Address)
Name and address of nearest living relatiVe or name of pertori
authorizing cremations
asE sfi ,ems /�S /2&p i
(Name) 1 (Address)
Relationship to the deceased
-6- ler F
Nam* of Funeral vT THE Nom i►ecHE `
I MPORTANT s -- CE.
I represent that to the best of my knowledge, the dectersed.�1°rr*s
has no r her body. (Circle One) sp0.r; �hc
pacemaker in his o
autha
rizatioh to nrr:^
I certify that 1 have the full power and _I
for the cremation of the remains ersonal direct
possessionsshavete" '
the cremated remains. that anY p rotect# de = end
been removed or may be destroyed, and agree to p
View Crematorium fro* any and all claims
and save harmless Pine
which
and demands for loss
Or dama
ges
the cremation mofe said in vy
re r+
mains
reason of or connected
ted whether such claims or demands are or are not who(
directed,
groundless# false or fraudulent.
'94o7 '6
( itness► (Address)
—L 4(SIgnature of Relative or Legal Re,p. and Address)
�00
Signed on this dates-
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 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. Caskets and containers must be of combustible material .
Nq • styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
accepted.
6 . Unless other arrangements are made the cremated remains will be
tuaiied 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 $195 .00
'hildren (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 .
tp
"Customer's Designation of Intentions"
Name of Deceased: 14
Cremation:
(scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
JN Burial at El Return to Family
El Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge a copy of
this form.
(Signature) �)-j bf115
(Printed Name) (Reltaoon.14,�X.p
6
(Addreas)
(releph.n.Number)
"Cremated Remains which shall not have been claimed withili th to Of
cremation may be disposed of by this firm by placement in,a'
Printed Name of Funeral Director otgnature of Funeral Director
or Undertaker or Undertaker -lc�
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REM JNS
Cremation:. (Actual Date) (Location of Crematory)
Disposition of Cremated Remains: tr-r--
(Manner Of Disposition)
(Location)
(Date)
Name Of Person Making Disposition Signature Date
#9 wHrrE-Funeral Home copy YELLOW Family Copy PINK:Crematory Copy CUSWEN Rev.V96