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Blanchard, Glennis 7 r1rO OF QUEEN,5BU9 Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director `dxt'-5061 ,L&l�(G&&12 Case # Date of Cremation 1 d2 '— 19 '- a©aco Time Cremation Started�� , � r Time Cremation Completed rot � ) C Type of Container Remarks : � �— A,�.4 / '7 a/AO i 5�19fAll Jde /0 � �N1 , DEC-19-2000 10 :47 AM 275363252624273 762 4383 P. 01 a � TOM OF oUEEP498 V pINE view CCMBTCRY �^ a CREMATORIUM ducker Road, tiu*tMV6ury, New York i11404 Phone ($1R) CrematorIUM 745-4477 or 0 no answer C*Aetrry 748^6476 AUTMRIzaT(OM TO CRKMATE The undersigned r•ocuests and authorises Pima view Creaatorlmm, in [st"-,_. .i; C� ri�l►C�r� wt.t}1= rnf_-#.ub,Joee to its Rules and Regulations to a creaata the raimaitta of - t macs (son) g6A 1 Zofs� Qit rat t? ! ( i yl (gtate) (Zip C*de) who died on �0 ;lda _:� €..,..�,::w • �.G�� at TL J v L A/ (Place) C a"dr^fs sY Name and living, r1latiyr _or, /Mae of person out herlsdM)4r,RreN+t&AodOrl x4tor-a�;s ''w - = . . n., rys tter•I/r 44; (Name} �'" (t$IdZMRI}iCiM .r. caotA The #rid 0%hthov-a�$��# �idelawra��i f!w lrbh Iii�v1K5 d efieia7sdlt crenate tht rem*ans Nam* of funeral Name �[/>�J7�h� �"✓ �''��' � 'r ,�e.., I represent •hit to the best Of my knowledge, the doeessed has or troat ) end " l certify that I have the full power and authorisation to arrange the or@40ted re*atne, that any personal possessions hove either teon._ removedvr day be , ,d�stro dt and a�ril�y-„ts.�„pr0�ti�a.yi1:(t!�!t and ea e: ha mleie Pine ujMWC+INlertoriu* from my and all claims and demands for loss or damages which may be aedo against thew by' K'!it0 °:3=0�°Oro&Convoc�twit-WiSh i tVIV!a�rlrl�y}']�Ip!F -911f fir _ r"eNai11! as AIMdAR�thSl+ ilswt('oatee*h claims or de*ands are or are not wholly groundless, false or fraudulent. tWitRstiil (Address) e ion to cc e riativr or Legal Rep. and Address) " 00 V oaJw�hl. aate� �� I reoreser5t that to the ugst of my hnowled�:e get de�easetf has or - I nn p#cemak*r in his or hie body. 4circir I certify that, : havr the r .a power allfj to fora trio cremation of tits r^ee&-ms and to dir-vct t F6 i%Pvv,�"*h we Otte c?'*matoO a*** tns, that arty p+r6onal PD%%V%W10nt hovw aitha: veers r,wvvvvd Ur may tiv cc.i nec,.xvc Wit 5 ti'rK' G `,l,MtaL: W7+ 7• HM1C t'c.:.. .,ir ' it direti:teef,• ; w$s•xiex such c.taims or at-v not ter" �i nr groundless, false or fira;+d�( ent• _ ,,� dWitfle6s) (Address) 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 POLICIES, RULES AND REGULATIONS L. 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 ,vid 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 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 styrafoam 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.to the Mail within three days of cremation funeral home handling the service. There will be a $20. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $ 185. 00 Children (age 13 months to 12 years) si1,0. 00 Infants ( stillborn to 12 months) s70. 00