Keeler, William L rl-nWN OF QUEENSBU9�Y1
C/
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ft1,P-*. �.Qr
Name (,V 1 �� /G� 11'1 2-Q.� �-- Case # ,�
Date of Cremation / _ 02 d,Gb l
Time Cremation Started 6/.-4-0, /9"M
Time Cremation Completed bt-ml
Type of Container WC)C),, C AS/kPT-
Remarks :
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17
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TOWN OF QUEENSBURY
PINE
*A�VIEW
pCE{{M� EkTERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) CreMatgfiurn; 745-4477.(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:
William E. Keeler Male
(NAME) (SEX)
130 Harrisburg Road Stony Creek New York 4rAW /a 87$
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 23rd day of January 2000
at His home on Harrisburg Road, :in Stony Creek
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Shirley A. Keeler —'130 Harrisburg Road, Stony Creek, NY 12878
Relationship to deceased Wife
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT
I represent that to the best of.my knowledge, the deceased.4p#W has no pacemaker in his golft
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 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
em by reason of or.connected with the.;cremation of said remains as directed, whether
such clai s or demands are or are not wholly groundless, false or fraudulent.
3809 Main St. , Warrensburg, NY 12885
(WITNESS) (ADDRESS)
130 Harrisburg Road, Stony Creek, NY 12878
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 01/24/01
DISPOSITION OF CREMATED REMAINS -_
I hereby direct Pine View Crematorium to'dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: Return to the Funeral Director
If pulverization of cremated remains is requested, check here _XX
POLICIES, RULES AND REGULATIONS
1. The crematorium will L a open for cremations 5 days a wec*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 tl'.e Pine View Cemetery, Quaker Road,
Town of Queensbury.
z
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 authurity,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 anc' 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:onnected with the cremation of said
remains and/or dispositilon 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 suite Die alternate container. Caskets and
containers must be of comb-istible 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 rem.-ins will be accep,--d.
6. Unless other arrangements a:a made the cremated remains will be mailed via Registered
U.S. Mail within three days"of r;remabon to the raneral home handling the service. There will
be a $20.00 charge for this'service.
Cremation, Administration Costs and Recording F-:e: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants(stillborr to 12'months)$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.