Willett, Sheldon LO YYN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ' T �d
Name :5:6 �Q� ��;�, T� Case #
Date of Cremation a g006
Time Cremation Started Z I N �/Iu i
r
Time Cremation Completed �3"/S'� /9rm 1
Type of ContainepCi fg)Le—&7� GC-,�Z:- 7*w-Pll
Remarks : �.�—
��"� •ill ,
I
I
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 subject
to its Rules and Regulations to cremate the remains of:
Y L L6
(NAME) (SEX)
Rk\h-LR�0�2 ALL C�elLSuS l
(STREET (CITY) (STATE (ZIP CODE)
who died on <�(% day of rcc..-,k P, 20Qr
at GIG- oLI-o uD
n .o G�
(PLACE) (ADDRE S)
Name and address of nearest living relative or name of person authorizing cremation:
T F� M, VA)ILI.L-11- "1 14hWLAT,)o LJL GLMS FRLLS -1) I
Relationship to deceased
s
Name of Funeral Home -n
C �
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has no acemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation .° -3mains and
to direct the disposition of the cremated remains, that any personal possessions I* _ ?"er been
removed or may be destroyed, and agree to protect, defend and save harmless Pine VJ
Crematorium from any and all claims and demands for loss or damages which may be ma:iz
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.
E v -
W[T
NESS) 4(ADIR' ESS)
v L L E Lt_S),-n�{
(MINIATURE OF RELATIVE OR LEGAL REP. A D ADDRESS) c j
Sig d on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here
-m -• 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, arrangements can be made for Saturday. Prearrangements
----� by-teleoone for acceptance of remains is necessary."
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
-mewn-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 personal possessions
have either been removed or may be destroyed and agree to protect, defend and save
-- -i�er+ lessf�lr�e 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 and/or disposition of said remains as directed, whether such claims or demands are,
ur-ar"ot-wheR) -gf-eund4ess;-false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
$ —4: -AWfemsifm-must•be-eneased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
Nqt T,�'IL1'e.question relative to cardiac pacemakers must be answered on the authorization to
creina a°t`o'tFrti`b�fdi°er'the rernaiins will be accepted.
Unless other arran ements are made the cremated remains will be mailed via Registered
bns 5 Mail within tPrie days df cremation to the funeral home handling the service. There will
nest d"1 i
�g.a $20.�0`cfiar'ge for this service.
r'remation, Administration Costs and Recording Fee: Adult$225.00 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.