Bourgeois, Gizele rrncKN OF QUEEN
,5B U�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director CL �,�,�
Name Case # 3��
Date of Cremation _" �C3
Time Cremation Started /a ;_5`��i�1�1
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Time Cremation Completed � Lo�j /10/m
Type of Container r—
Remarks :
/a ;S,
21
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TOWN OF UUEENSUURY
PINE VIEW UEMETE14Y
A
CREMPFURIUM
Uuaker Road, Uueensbury, New York 12604
Phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHOR Un T ION TO CREM ITE
The undersigned requests anti authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
C,4 -z-ek, tS
(Name) (Se")
(Street ) wd (City) (State) (Zip Code)
who died on day of 00
at V J14 y
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
60L�L 25 Z- V
(Name) (Address)
Relationship to the deceased ' s^�
Name of Funeral HomeTv�"1����(�.�—���. ` SwNAL�
IMPORTANT:
I represent 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 reproved 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
g ndless, false or fraudulent.
(Witness) (Address)
(Signatur ARel tive or Legal Rep. and Address)
Signed on this date : �� ��/ • O
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to disposr3 of the cremated
remains as follows :
Mail to
Other arrangements ' - please sped fy :
If pulverization of cremate remains is requested, check here
POLICIES, RULE9 AND REGULATIONS
i . The crematorium will b.e
7:00 A. M. - 3: 30 P. M• open for c_remat.i ons 5 days, a week
tlonday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements b
telephone I'°r y �
acceptance of remains is necessary. Y
2• line View Crematorium
View Cemetery, is ivcated• on the grounds of
qualcer Road, sown of the Pine
Uueensbury.
3• An authorization For cremation properly
next of kin or othE�r. I P perly signed by the nearest
the authorized person stating that they do have
Power and authority to arrange For
remains and to direct the dim the cremation of the
that ally personal �f�ositior� of the cremated remains,
destroyed and agree osto protect
have either been removed or
y be
View Crematorium From
to protect, defend and save harmless aPine
damagesmay ariY and all claims and demands for loss of
withgthewhCremat ioneOFade saidgainst remainsllanc b
remains as directed, whether y reason of or connected
1/or disposition of said not wholly groundless such claims or demands are, or are
in addition , false or fraudulent. This authorization
remains. to a regular burial permit must accompany the
4- All remains must be encased in a
container. Casfcets and casket or suitable alternate
No
material . in
must be stainers or• plastic_ containers will of combustible
be accepted.
5• Tl�v question relative to
on the authorization at cardiac pacemakers must be answered
accepted. cremate form before the remains
will be
6• Unless other
be mailed -via Re915te ell U S. are made Elie
to the funeral home handl ins• Mai 1 within three mdays •o ated remains wi l 1
charge for this service, g the service. There will becremation
20. 00
Cremation, 'Administration Costs and
Children tags 13 months to 12 Recordin
to 12 months) i` g Fees Adult t1� 5. 00
70. 00 Years) t17,0. 00 Infants stillborn