Peck, Hollis TOUN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director GC46il 6d
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TOWN OF UUEENSDURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
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 Regulations to
cremate the remains of :
HDt<(s E_ fec -- tilde_
(Name) (Sex)
CVV 6-. ,) TeX ti S14.1cvo,
(Street ) Q (City) ' A(State) (Zip Code)
who died on Q1- day of y� '�' �0
at / IA L& `l S d`of l;a l�.V�/�-
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
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(Name) (Address)
Relationship to the deceased;�t� � '
Name of Funeral Home—li ��'�� ' C-�C—
IMPORTANT=
I nonresent that to the best of my knowledge, the deceased has or
as 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 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 or damages which may be made 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
grou Bless, false . or fraudulent.
1
(Witn ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date : � lot [60
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
P(JLICIES, RULES AND REGULATIONS
1 . The crematorium wi 11 b,e open for cremat.ions 5 days- a week
7:00 A. M. - 3:3. 0 P. M. r1onday-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 directeet, whether such claims_ or demands are, or are
not �jliolly groundless, false or fraudulent.
in addition to a regular burial permit This authorization
remains. mu accompany
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
aers
on the authorization to cremate form beforel� remains Must be answWilered
accepted. the
6- be
Unless other arrangements are made the cremated remains will
be mailed .via Registered U. S.
to the funeral home handling the lservice.
l within three days .of cremation
charge for this service. There will be a $20. 00
Cremation, Administration Costs and Recording Fee : Adult $ 185. 00
Children (age 13 months to 12 years) s ! ]•0, 00 Infants ( stillborn
to 12 months) s`j0. 00
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