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Moffatt, Shirley rrOQUEE5BU . V/ PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director &fi�Apl 1 Name f Case # �© Date of Cremation Time Cremation Started 4— oZ�n /pi`U` r J� Time Cremation Completed h I fA Type of Container o2N,U., C/95'"dfi' Remarks : e, 11— j i Al) 1 / ' 3e PA) TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12801 / Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777 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: Shirley M. O'Connor Moffatt Female (Name) (Sex) 3664 Main St. , Warrensburg, NY 12885 (Street) (City) (State) (Zip Code) who died on loth day of Feb. 3900 at Glens Falls Hospital (Place) (Address) u �: Name and address of nearest living relative or name of person authorizing cremation: .2 Shirley M. O'Connor Moffatt Pre - Need (Name) _�; .6 (Address) Relationship to the deceased Herself ^r Name of funeral home Alexander Funeral Home, Warrensburg, NY IMPORTANT: ;Nti is7r9':�7•^ I represent that to the best of my knowledge,the deceased #gas or : pac.QmA4 . i.cn`hii, or her body. (CIRCLE ONE) I certify that I have the full power and authorization to arrange, for •the;.cro�aign gfs tide remains and to direct the disposition of the cremated remains, that any personal possessions havelJp�ire 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 zthgr�,4rr-Qgt pp4#r,'('or.aconnected with the cremation of said remains as directed, whether such claims or demM34t :are,; era not, wholly groundless, false or fraudulent. C (Witness (Signature of lative or Legal Rep.) 3664 Main St. , Warrensburg, NY (Address) (Address) Signed on this date 11-9-88 Pre need 2-11-00 wiuness DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: - Mail to Other arrangement - 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_.ac_54CRddy_s,, arrangements can be made for Saturday. Prearrangements by telephone for acceptance of remains is necessary. 2. Pine-mew -Crematar--ium 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 d10' ave ' 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 bT—'M'TUffd-afid' 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 ar3�e,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. 5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form before 6. Unless other arrangements are made, the cremated remains will be mailed via Registered U.S. Mail within � �t�ys`6f cremation 'to the funeral home handling the service. need -. Cremation, Administration Costs and Recording Fee: Adult $125.00 Children(age 13 months to 12 years) 80.00 Infants(stillborn to 12 months) 45.00 Shipping container, carton and packing fee for shipping and registered priority mail with return receipt included in the above prices. ADDITIONAL SERVICE Storage of cremated remains-per month $ 2.00