Smith, Clinton TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name CL S� 1 2 Case #
Date of Cremation 7 — � � — RO<5o
Time Cremation Started 1, t
Time Cremation Completed
Type of Container e-- /�f� oe2ZCD
Remarks :
f<9
TOWN OF UUEENSUUfiY
DINE VIEW CEMETERY
A
Cl(EMA CU11 I UM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHURIZATIUN 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 :
_ LTG/;.�-7 �.l,Lr; �t
(Name) (Se►c)
(Street ) / 1 (City) (State) (Zip Code)
who died on !�""" day of 44!-Or/
at / N
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
_ Zoe f�J i /P!9V f /Cow
(Name) (Address)
Relationship to the deceased
Name of Funeral Home���/�/1� �/G�'
IMPORTANT=
I r hat to the best of my knowledge, the deceased has or
as no pacemake 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
groundless, false or Fraudulent.
'Ia& c ,Q ✓� ,ry
(Witness) (Address)
LA>X44-447 'n'2 3 9" 4� /ef, ���
00 (Signature of Relative or Legal R . and Address)
Signed on this dates :&Z.1 04
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
PI.11-I C I ES, RULES nND REGULATIONS
1. 1*1)e iu;i; w I l b,e open for cremations 5 days a week
7z00 A. 14. - : :30 P. 14. 14onday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telepFrone for ,acceptance of remains is necessary.
2. Pine View Crematorium is located- on the grounds of the Pine
View Cemetery, Uualcsr- Road, ''own of llueensbury.
3. An authorization For cremation properly signed by the nearest
next of loin 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
that of (fie cremated remains,
any personal possessions have either been ' removed
destroyed and agree or may be
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 groundless, false or fraudulent. This authorization
in addition to a regular burial permit remains. must accompany the
4. All remains must be encased in a casket or
container. Caslrets suitable alternate
and containers must be :,!° L
R+aterial. No styrafoam or' plastic_ containers will be accepted.
5• Tl1e qu estion 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
be mailed -via Registered U. S. remains will
to the funeral home handling tile service. three
dwillof cremation
charge for this service, 20. 00
Cremation, Administration Costs and Recordin
T11
d ri (age 13 months to 12 9 Fee : Adult f1(15. 00
a months) t`)0. 0rD Years) ti1,0. 00 Infants ( stillborn