Simpson, Berit r'_o WN of QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6, /r/�/O
Name�,��/ r im Case #
Date of Cremation - acco
Time Cremation Startedoy /4 //�/� /
,[a �Time Cremation Completed � e �,d I I
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
-inri t i;-I:con Femal e
(Name) (Sex)
7 Iroquois Lane Lake Geor¢e , New York
(Street) (City) (State) (Zip Code)
who died on 2 nd day of November , 2000 hb9_
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Carl WT S i ry:rs c)n, Jr 11 Temple St . Rutland , Vermont C 5701
(Name) (Address)
Relationship to the deceased S o n
Name of funeral home To-:s;i np. Fi)rPral Home' 39 Washington St Rutlannd Vt 05701
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or has no pacemaker-,ini-ha.5�.:or her body.
(CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremati6h'bf,,"'tW, remains and
to direct the disposition of the cremated remains, that any personal possessions have ei;tX4iK=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 redimi- -of tor-gconnected
with the cremation of said remains as directed, whether such claims or demands are",WPe not, wholly
groundless, false or fraudulent.
gA��
(Witnes ) (Signature of Relative or Legal Rep.),
3!� Washinatnn St _ R1,tland Vt,
(Address) (Address)
Signed on this date November 9 . 2000
DISPOSITION OF CRENATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to Tossing Fijrpral HnmP ' q Wash- r-tin St . Rutland, Vt. 05701
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here X
-�^- POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday No
Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance
of rematnr-fis�necessary.
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town 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 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 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 ar..e,..,.ar_.are not wholly groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains.
4. All xamaa-n.s--must .be encased in a casket or suitable alternate container, Caskets and containers
must be of combustible material.
5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form
before ih�e+Tema ryns will be accepted.
6. Unless other arrangements are made, the cremated remains will be mailed via Registered U.S. Mail
within 6�,Fq.,Aays of cremation to the funeral home handling the service.
CremationjEAdministration Costs and Recording Fee:
Adult $125.00
Children(age 13 months to 12 years) . 80.00
Infants(stillborn to 12 months) 45.00
Shipping container, carton and packing fee for shipping and registered priority mail with return receipt
included in the above prices.
ADDITIONAL SERVICE
Storage of cremated remains-per month $ 2.00