McKeighan, Raymond rro OF QUEEM
,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorAc CLF` ,k fil'V
Name T/l/9�/1/�9i 11�� /ILK%/��J�17'/9/X Case #
Date of Cremation '
Time Cremation Started f
Time Cremation Completed `�i p ^ 04 f
Type of Container
Remarks :
�7"'
1
I
TURN OF UUEENSIlUf1Y Cjl{S l
PINE VIEW CEMETERY /-�/r�
a
CREMMUR I UM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATIUN TU CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cre the remains of : .
G
( me) (Sem)
05 I
(Street ) (City) (State) (Zip Code)
2�
who died on ? day of
NJ-
at Nk-A- ��y- (�
(Place) JAddress)
Name and address of nearest living relative or name of person
auth izi g cremation : r&-1,fVti�O� `�r
AL 5A
( ame) (Address)
Relationship to the deceased 1
Name of Funeral Home �
IMPORTANTs
resent that to the best of my knowledge, the deceased has or
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 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 Pixie 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
groundless, false or fraudulent.
(Hit ess) (Address)
(Signature of Rela ive or Legal Rep. and Address)
Signed on this date : L—J1y�
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, 13ULES ANU REGULATIONS
1 • 1A. r_reaator`luiii will
7:00 A. M u.e open For cremations M. - 13:30 P. . H r^
onda y• No
5 days, a week
arrangements can be made For Saturda Holidays or Sundays,
telephone (`or acceptance of remains is necessaPyearrangements by
2. Pine View Crematorium is located- on the grounds of the Pine
View Cemetery, Quaker-Road, 'rown of Queensbury.
3. An authorization For cremation properly signed by the nearest
the of lain or other authorized person stating that- they do have
the power and authority to arrange For the cremation._.remains and to direct the disposition of of the
the cremated remains,
that any personal possessions h::ive either
destroyed and agree to ;protect, def been removed or may be
---V end and save harmless Pine
-iew 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
a^emains as directed, whether claims or demands are, or are
not wholly groundless, false or Fraudulent.
in addition to a regular burial This authorization
remains, permit must accompany the
4• All remains must be encased in a casket alto;-n
container. Cashets and or selital,le
containers must ate
material. No styrafoam or- plastic containers willobe combustible
5• The accepted.
question relative to cardiac
c the authorization to to
Pacemakers must be answered
accepted. form before the remains will be
6• Unless other arrangements are made the cremated remain
io mailed -via Regl stared U. S. Mai 1 within three days ,of cremation
to the funeral home handlin s will
c►iarge for this service• g the service. There will be a ration
ao. 00
Cremation, Adm: nlstratlon Costs and Recur-din
Children (a., 13 munths to 12 g Fee: Adult $185. 00
i
to la months) s`10. 00 years ) s ! ].0. 00 Infants ( stillborn