McAfee, Joanne rl-O`1 N OF QUEENs5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorj9" c/' 'kL
Name �/9/j�/Y � / Case
Date of Cremation pl ` — o 4x)o
Time Cremation Started , Arm �
Time Cremation Completed5r W 19fAA 1
Type of Container 6z W& IM l57-o .1!E-6/t" 7 YZE
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:
J Ii A!i:i�_' K 'N fc=
(Sex)
(Name)
13524
15;028 Vallai Drive ClaZ ton NY (State) (Zip Code)
(Street ) (City)
who died on 28th
day of Jaauary IV 2000
at N;frk ',adical Cant er ^ La'.c^
(Place) (Address)
Name and address of nearest living relative or name- of person
authorizing cremation:
ngcAfo i
i r
F � Na X.
( (Address)
(Name)
Relationship to the deceased
Tj ^� r' jr 77 S_�r�:^� 1�V_? T„':i_� 1-:1 lei i�
Name of Funeral Home '1 ;STY 11294O
JPMRTANTe knowled a the deceased has or
I represent that to the best of my (Circle One) ' �
has no pacemaker in his or her body.
I certify that 1 have the full power and authorization to arra
for the cremation of the remains 4rd todisessionsshaveteithF
the cremated remains, that any psonal pos
been removed or may be destroyed, and agree to protect, defend
w Crematorium from any and all claims
and save harmless Pine Vie
and demands for loss or damages which may be made against -them by
reason of or connected with the cremat-son , of -s4id remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
4k L 2,7 S:ara:!!- Av La•{c placid, NY 12946
t1_nes&s) (Address)
�-g U,o,,.G-r OR, LA Ylliv �Y
( icgmature o Relative or Legal Rep. and Address)
Signed on this date:
( �8 a-Uuo
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Cumminjs Fun ' l Service, Inc.
g20 John Street Clayfton, IVY 1 624
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here;{x
h^ 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,
d-rrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
Z':"e ';Pihe 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
nt.-e i-perst.qna,l• ,,possessions have either been removed or may be destroyed
and agNje 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 reguTar"'bur al permit must accompany the remains .
4 . `AIT�"'"�remans must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
.... , y.r pamt or plastic containers will be accepted.
5. The question relative to cardiac pacemakers zust be answered on
hen�astho.;izat,ion to cremate form before the remains will be
sv6d ,
other arrangements are made the cremated remains will be
-Aa1kftd 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
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 .