DeLong, Baby Boy rrn' N OF QUEEVBUrkY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �X./9 �
Name VICA166;2 Case #� �
Date of Cremation /Z— -7-/ — oZ<n�
Time Cremation Started 1 ?5 044Nl 1
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Time Cremation Completed �—! 1-5-4 r �(
Type of Container
Remarks :
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road Queen
sbury, New York 12804
Phone(518) Crem atorium:t745-4477:(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:
Baby Boy DeLong Male
(NAME) (SEX)
19 Chestnut St. , South Glens Falls, New York 12803
(STREET) (CITY) :;.:; (STATE) (ZIP CODE)
who died on the 17th day of November 2000
at The Glens Falls.,Hospital
(PLACE) (ADDRESS)
Name and address of nearest living relative,or name of person authorizing cremation:
Rickie beLong — 19 Chestnut �t. ,.. South Glens Falls, NY 12803
Relationship to deceased Father
Name of Funeral Home Alexander Futeral Home, Inc.
IMPORTANT
I represent that to the best of.my knowledge, the deceasefteogotas no pacemaker in hiss
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 promated,: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
t them by reason of or.connected with the,cremation of said remains as directed, whether A
such c s or demands are or are not wholly groundless, false or fraudulent.
John S. Alexander — 3809 Main St. , Warrensburg, NY 12885
( ITNESS) (ADDRESS)
19 Chestnut St. , So. Glens Falls NY 12803
(SIGNATURE RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 11/18/00
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to-dispose of the cremated remains as follows:
ra Home
Other arrangements-please specify: RETURN TO FUNERAL DIRECTOR
If pulverization of cremated remains is requested, check here XX
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 remains is 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 or 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 must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or 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 be 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 a$20.00 charge for this service.
Cremation, Administration Costs and Recording FW_,AdU,1t$225.00 Children (age 13 months to
12 years) $115.00 Infants(stillborn to 12 mo s) $75.00
* Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional$50.00.