Munson, June OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1140
Name /�/fia5o ,v Case # 3-s3
Date of Cremation /d
Time Cremation Started !J L[Ly dim )
Time Cremation Completed �1/ !�I A rAA t
Type of Container
Remarks :
)<9 e-,5"X AfA
TOWN OF ❑UEENSUURY
PINE VIEW CEMETERY
CREMATORIUM
' Quaker Road, Queensbury, New York 12604
Phone (516) 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-t-he remains of:
(Nama) (Sem)
(Street ) (City)( / (State) ( Zip Code)
who died on day of ''.0��
at . S N
(P•Iace) (Ad ress)
Name and address of nearest living relative or name of person
authorizing cremation
(Name) (Address)
Relationship to the deceased y� � �"
Name e of Funeral Home �i �IAA► v�iy _ 1�/�
IMPORTANT:
I r,epr ent t 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 authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains. that any persoral possessions have eiiher
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
undless, false or fraudulent.
(Wit ss) (Address)
(Si a ur o e at ' ve or gal Rep. and Address)
Signed on this date :
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
P(JLICIES, RULES AND REGULATIONS
< 7'lie crematorit.im �w: II b, open. for cremations 5
7:00 A. M. - Monday-Friday. days���;. _. west(
arrangements can be made for Saturday. holidays ngor # Sundays,
telephone for acceptance of remains is necessaryearraements by
2. Pine View Crematorium is located- on the grounds of the Pine
View Cemetery, Quaker' Road, ''own of Queensbury.
3• An authorization For cremation properly signed by the nearest
next of kin or Other, authorized person stating that they do have
the power and authority to arrange For the cremation off the
remains and to direct the disposition of the cremated remains,
that any personal possessions have either been remove4
destroyed and agree to y be
protect, d or:ect, defend and save harmless aPine
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,
not wholly groundless, fals or are
e or fraudulent. This authorization
in addition to a regular burial permit remains. must accompany the
4• All remains must be encased in a casket container. or suitable alternate
Casl(ets and containers must be of
ble
material. No styraFoam or plastic containers will be accepted.
5. The question relative to cardiac
Paceswe
on the authorization to cremate form beforekthe remains must beawillrbe
accepted.
6• Unless other arrangements are made the cremated remains will
be mailed -via Registered U. S. Mail within three days of cremat'von
home
to the funeral handling the service. There will be a $20. 00
charge for this .service.
sevice,
Cremation, Administration Costs and Recording Fee: Adult $185. 00
Children (age 13 months, to 12 years) sl ].0. 00 Infants ( stillborn
to 12 months) s`70. 00
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