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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 ,y Remarks : ���-- ����� A,/ �� Al 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 .