Tyler, Augustus Jr, TOWN OF QUEEN,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 2d
Name &LL-d,j 793 Case # -5e
Date of Cremation _ / — -Inco
Time Cremation Started
Time Cremation Completed �l' S �/M t
Type of Container A)ek:9 ,V e: S5- �k7� 72; Pz5
Remarks :
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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.supject
to its Rules and Regulations to cremate the remains of:
ACIGUSTUS C. TYLER, JR. Male
(NAME) (SEX)
171 Old Post Road, Ballston Spa, NY 12020
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 31 s t day of January 20 00
at Maplewood Manor Nursing Home, Ballston Spa
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing vematkon r71s;-..
Nancie J. Tyler, 171 Old Post Rd. , Ballston-€rp Miff 12020
Relationship to deceased WIFE
Name of Funeral Home William J . BUrke & Sons F-aneralo� Hmmez„ L.
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as na pacemaker,in bis or her
body. (CIRCLE ONE)
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 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 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 not wholly groundless, false or fraudulent.
;/�, 628 N. Broadway, Saratoga Sprinas , NY 12866
(WITNESS) (ADDRESS)
SIGNAT E OF
( R LATIVE OR LEGAL REP. AND ADDRESS)
yr
Signed on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
u�
Other arrangements-please specify:
if pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
--T- ne 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
-bTtetephone for-acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
"O e"_Town%f t' 66ensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
'.perscm 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 or damages
,,CIF which may be'made against them by reason of or connected with the cremation of said
remains and ldr bs tion-of said remains as directed, whether such claims or demands are,
of are not wh6lly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
^r 0 c i3 ri
4. All remains must 6 encased,in a casket or suitable alternate container. Caskets and
containers must be'of combustible material. No Styrofoam or plastic containers will be
accepted.
question relative to cardiac pacemakers must be answered on the authorization to
11 F ri l i�cr�;riiate form before-the remains will be accepted.
-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$22--5.00 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.