Johnson, Charles rrO+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENI SBURY, 1VEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,/y! / ,&i C41myr
Name �i/7// �j a�jyT A66/� Case #
Date of Cremation
Time Cremation Started / r�l/�
Time Cremation Completed `1 I / M t
Type of Container cz1ypf }/
Remarks : ,� /
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06/14, 00 22.34 FAX 13132713861 KINKO'S DEARBORN 1-FORD 1@003,005
JUM—14-00 12_57 PM CLARK FUNWRAL 140MM 51!252=ZZTQ P. 01
1
TOWN OF QULENSBURY
PINE:VIEW CEMETERY \,
C"ICREMATORIUM
Quaker Road, Queensbury,Now York 12604
Phone(518) Crematorium 7454477(if no answer)
Cemetery 74S-4476
I
AUTHORIZATION To CREMATE I
The uhdVrsigned requests and authorizes Pine View Crematorium, In accordant,e with and subject
to its Rules and Regulations to cremate the remains of:
' CtiARLES M. ,FOFINSON MALE
NAME) (SEX)
25 1River street -Lake rlacid, NY 12946
STREET) (CITY) (STATE) (ZIP ODE)
who dji on 12 th —_-- day of jUne 20 00_
i
at 251 River Street; a
MACE) (ADDRESS)
Names d address Of naarQst living relative or name of person authorizing crerr ation,
Mr herine Johnson
Relatfo hip to deceased
Nr�fTle of Funereal Horne M. . Take P 1 a i d o
NY 12946
IMPOIR ANT
I Mpres int that to the best of my knowledge,the deceased or has no pace sitar in his or her
body. ( IRCLE ONE) _hal
I oertffy hat I have the full power and authorization to arrange for the cremation of the remains and
to direr the dlsposiden of the oren1ated remains, that any personal poesessions have either been
remov or may be destroyed.and 2�gree to pmtect,defend and save harmle Pine View
Croma rium from any and all claims end demands for loss or damages which nay to madll
against hem rom
an man of or connected with the cremation of said remains as irected, whether
ch al ems or de indsare or�a�re not wholly groundless, as or.fraudulent.
OL
g►s� _ (WITNESS) (ADDRESS) ' �-
��� i V YLiVl
�l (SIGNA ELATIV OR LEGAL REP. AND Abt)R SS) j
Signed on this data: Tung t d . a.00o
(� r �1 7
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00.14/00 _22:35 FAX 13132713861 KINKO'S DEARBORN 1-FORD 005"005
l•� +-. PG t� ;�y t'P7 CLPRK FU14r� AL HOME �185 $333ci
p• @1
DISPOSITION OF CREMATFED REMAINS
I hereby direct Pine View Crematorium to Wepose of the cremated rernalns as fol ows:
MSIItO es+ .,_ NX +2946
Other arr4ngernente-please specify:
If Pulverization of cremated remains Is requested, chock here
POLICIES,RULES AND REGULATIONS
I. The t;rematorlum Will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M.Monday-
Fr1day. No Holidays or Sundays, arrangements can be made for Saturday. rearrangements
by telephone far acceptance of remains is necessary.*
2. Pine Viaw Crer,owdum Is located on the grounds of the Fine View Cemeter J, Quaker Road,
Town of Gueensbury.
3. An authorlZation for crematlon properiy signed by the nearest next of kin or t ither authorized
person stating that they do have the power and authority to arrange for the c remation of the
rem$ins and to direct the disposition of the cremated remains, that any per nal possessions
haver either been removed or may be destroyed and agree to protect, Ref+en and save
hasTnlegg Pine View Crematorium from any and all claims and demands for ss or damages
which may be made against them by reason of or connected with the cre tion of said
remains and for disposition of said remains se directed,whether such clal or demands are,
or awls not wholly groundless,false or fraudulent. This author¢ation in atadditi In to a regular
buHgi permit must accompany the remains.
4. All rgrnains must be encased in a casket or suitable alternate container. C skate and
contoiners must be of combustible material, No Styrofoam or plastic contaii era will be
accepted,
5. The question relative to cardiac pacemakers must be answered on the aul dration to
cremate form before the remains will be accepted,
8. Unieas other arrangemenIs are made the cremated remains will be mailed is Registered
U.S.;Mall within three days of cremation to the funereal home handling the si rviow There will
be a$20.00 charge for this service.
crematlon,AdmInlstrsation Costs and Recording Fee: Adult$225.00 Children(ige 13 months to
12 years)$115.00 Infants(stillborn to 12 months)$76,00
Additional $50.00 charge for cremations done after 3:00 P.M, Monday throug Friday.
Cremations done on Saturdays will be charged the additional S50.00.