Ennis, Frances L O WN OF QUEEN, L RY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, 'XEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M rclC Ilbl�
Name /— lyG� �iYn�!S Case #
Date of Cremation �— o`�N
Time Cremation Started �1')M t11A t
Time Cremation Completed
t
Type of Container
Remarks :
tilArM I
l/ - ! ' )9/AA f
V
TOWN OF UUEENSUURY 26
PINE VIEW CEMETERY ,V)
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:
(Name) Sex)
y0 ` 4
(Street ) (City) (State) (Zip Code)
wFio died on day of A49ulf/ o
at_ c/
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
(Na ) (Address)
//..__,,LL
Relationship to the deceased !/�i1�u`7&e
Name of Funeral Home /!�`Cle�l�✓
IMPORTANT:
I re-pcesent that to the best of my knowledge, the deceased has or
has (no pacemaker in his or her body. (Circle One)
I certify that 1 have the full power and oath^rz _at ?e.. to arra^ge
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
gro ndless, false o_r, fraudulent.
rlit
(Witness) (Address)
(Sig ture of Relative or Legal Rep. and Address)
Signed on this date : f/7, /O0
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify :
I f
Pulverization of cremate remains is requested, che.Ck hereY::':.
POLICIES, RULES AND REGULATIONS-
.
1. The crematorium will b.e open for cr•emat,ions 5
7:00 A. M. - 3:30 P. M. hionday-Friday, No Hol idays"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.. P*np
View Cemetery, Uuaker' Road, Town of Queensbury.
3. An authorization For cremation properly signed by the neares is
next of kin or other, authoied t
the person stating that they do have
power and authority to arrange for the cremation ok�pl
remains and to direct the disposition of the cremated rrema,";.rs; ,
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 to=ss of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of... j,'4j q
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This authorizati
in addition to a regular burial permit must accompany the
remains.
f�1.41
ti• All remains must be encased in a casket or suitable alternate 1j
container. Caskets t";t co.stainer's must be of
material. No styrafoam or combustible
plastic containers will be accepted.
5• The '� �
question relative to cardiac pacemakers must be answered.)
on the authorization to cremate form before the remains will b
.rt
accepted.
6• Unless other arrangements are made the cremated remains will
be mailed -via Registered U. S. Mail within three days of cremation
to the funeral home handling the service. There will be �1
charge for this service, a s20. 00
Cremation, Administration Costs and Recording Fee: Adult $ l 5.
Children (age 13 months to 12 years) sl ].0, 00 00
to 12 months) s`10. 00 Infants fs18