Bain, Cindy 70 WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '�/� /�
Name ' AAt/IJ Case #
Date of Cremation --�2 —
Time Cremation Started
Time Cremation Completed p2! )121 (�
Type of Container /.��,0 � �'� 7-- oZdO,,
Remarks :
I
I
I
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 774-44776or if no answer
Cemetery
AUTHORIZATION TO CREMATE
s Pine V in
The undersigned requests and authorize
and Regulat ons� to
accordance with and subject to its Rules 9
cremate the remains of:
FEMALE
CINDY BAIN
(Sex)
(Name)
178 WEST ROAD, ARGYLE, NY 12809
(State) (Z.17;7tode)
(Street ) (City) . s .;,.: :..
of FEBRUARY y 2000
27TH
died on day u
who ._
at HER HOME
(Address)
(Place)
Ir
nearest living relattve;. q.r� ,;,n,.*p person
Name and address o f near
authorizing cremation:
MARJORIE BENNETT, KILMER ROAD, ARGYLE, NY 1280:9,, : ;;,;; c:'C
(Address) _. .. , ",E rnic'me.
(Name) I'..;t^. TC',i
Relationship to the decease
MOTHER isi?Ud
., _.� ;. „�r .r
M.B. KILMER FUNERA,L,.,HQM.�;,. ;; , acisrnsi IIA .4
Name of Funeral Home .� clr r zien:e,Ina�
bGJ9��� j
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my � }rcfir�Ori>e`l "� �nr G
has no pacemaker in his or her
.ti
I certify that I have the full power and authorization tOV o arrange
for the cremation of the remains and, to diredt'` t 01 '1 , either
the cremated remains, that any pers-ona►1l-','1'3d`_. 4ViV_l " defend
been removed or may be destroyed, and" agr *p' t4i 01, �A t9
and save harmless Pine View Crematorium . flrps `anx, f,antd�� all claims
and demands for loss or damages which `maY, 040g, , -9�!i�?,,� ;them by
reason of or connected with the c emat1 oars°or�aare not
directed,directed, whether such claims or d
groundless, false or fraudulent.
(Witness)
(Address)
i
�(Sgnature of Relative or Legal Rep. and Address)
Signed 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 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,
arrangemehts can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
2 . or 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
persona' 'possessions have either been removed or may be destroyed
and agree to protect, defend and save harmless Pine View
-erema 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
dtT€ote'd---wtrether---such claims or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to
a regular burial 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.
19r 10 air+ ^r 18'�smsosG c_
5. The question relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
need igrgie
6 %c' 6r`e angements are made the cremated remains will be
m ► .Wa' is "It4k#b r 'd �J-.S. Mail within three days of cremation to
'v'fiifeiril hditiCi-' iiatidling the service. There will be a $20.00
charge for trYrf' `s``ePvice.
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.