Dudley, Albert rf-O l+N OF QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director��'
Name_.&h6cr ak)�z Case # M 3
Date of Cremation anon
Time Cremation Started
Time Cremation Completed PI
Type of Container Jq0_P1_'!bx -�•&_,eW
Remarks :
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TOWN OF t.IUEENl3EURY
PINE VIEW CEMETERY
R
CREMAtunIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 1F no answer
Cemetery 745-4476
AUTHORIZATION TO CREMRTE
The undersigned requests and author-izot Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remaijns off '
(Sam)
(Name) -- [�"�� � I
(Street ) o
1� (City) �Stot (Zip Code)
� -�
who died on day of
at
(Place) (Address)
Name and address of nearest liVing relatiVt or Mane of perfoti
uthorizing cr ations
(Nave) ( ddress)
Relationship to the aced
Name of Funeral Home G� 1
IMPORTANT: the d�e(tased hays or
I represent that to the best of my knowledge,
has no pacemaker in his 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 disposi ion of
al possessions i
the cremated remainst that any person ct either
q
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium fro* any and all claims
and demands for loss or damages which may be made against th s as
by
reason of or connected with the cremation of said re
directed, whether such claims or demands are or are not r.iolly
groundless# false or fraudulent.
(Witness) (Address)
(Signature of Relat i or Legal Rep. and. Address)
L'X� — 3L�s Signed on this datet
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 cremate remains is requested, check here
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
telephone 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 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 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
raudulent. This authorization in addition to
groundless false or f
a regular Curial permit must accompany the remains .
4 . All remains must 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
the authorization to cremate form before the remains will be
accepted.
6 . Unless other arrangements are made the cremated remains will be
t 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 $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 .
i
5
Qumisbury, Ncw W,!*
(5 i h)197-1'11,f
"Customer's Degghation of Intentions"
Name of Deceased:
Cremation: I I'
(svh.auia i5ate) (Location)
Manner of Disposition of Cremated Remains:
El Burial at Return to Family M.A
X
1. J
11 Entombment at 0 Other (spec*) " -
`
i hereby designate the Disposition of cremated Remains and acknowledge receipt of a 0ow Of
this form. fiA F
(Signature)
!14
(Printea Name)
(Telephone Number)
("qu IJA �ate of
Cremated Remains which shall not have been clainie wituia -4) il
cremation may be disposed of by this firm by PlaC0tne4inWCP1VMl�-Jy.J;3 .14
Printed N of FuneralDirector of FuneW.Director i t3% &-t-4A* jJ
r Undertaker or Unaer"er b f:2�,Zs vo J4
e
S
TO BE COMPLETED FOLLOWING CREMATION AND DISPOft, S-
Cremation:— (Actual Data) (Location of Crematory)
Disposition of Cremated Remains: (Manner Of Di"xitio-)
(Location)
(Date)
Nant.of Person Making Disposition Signature Date
#9 WHITE:Funeral Home copy YELLOW F-4 C." PINK Crematory Copy CUSDMN Rev.4N6