Butler, Hattie TOWN OF" QUEEVBU y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_,9(J&'A 1<5r — /l//115C-
Name 72 Case #
Date of Cremation a
Time Cremation Started ���/ i9�/� r
Time Cremation Completed $rI'(Qj M i
Type of Container jo�/g �, �lj�„D
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Remarks : ���--
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TOWN OF OUEENSBURY �
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12604
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 Regu-dations ito
cremate the remains of:
L-2a
(Name) (Sex)
(Street) (City) (State) ip Code-)
LJ
who died on C--7 - day of
at k; P-- 72y.1
(Place) (Address)
Name and address of nearest living relative `Of,'I5`u;person
authorizing cremation: ..•M,;
(Name) (Address)
Relationship to the deceased
Name of Funeral Home i
IMPORTANT
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. . (Circ71 a
I certify that I have the full power and • authoriiatTontro'arrange
for the cremation of the remains and ,to. di.,,,,Q,c,t,,, p'„ s ion of
;
the cremated remains, that any personal ",Oi s ,�o:r).sh,ay.q� either
been removed or may be destroyed, and agr:eea; t ;tio ;�x+p, it defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be. made -ag:ains,t.. .t.hom by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, f se or raudulent.
1
(Witness) (Address)
Al
(Si ature of Relative or Legal Rep. and Address)
Signed on this date : -Z��
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to , : -44n r. J- i a z
Other arrangements - pleaser specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
An—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
.tAa.1.ephor�Q; 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 j55-V'r---d'hd 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-, t.-o- .protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss of damages
which maw 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 .o,r_ fraudulent. This authorization in addition to
a regular burial permit must accompany the remains .
4, 81. _remainsn_mus.t._be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material .
No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on
i't`ieh -to cremate form before the remains will be
accepted.
tither.art I&ngements are made the cremated remains will be
� d; a"= eg,Ystered U. S. Mail within three days of cremation to
to fieral' home handling the service. There will be a $20 . 00
ch= .fie for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 , 00
Children (age 13 months to 12 years ) $115 . 00 Infants (sti11DOrn zo
12 months) $75 .00
* Additional $50 . 00 charge for cremations done after 3 : oo p_m-
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .