Terrell, Charles rroWN OF QUEENBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,��X
Name CIM F�5- Case #
Date of Cremation ox — l— ozdd/
Time Cremation Started �e.3lI ,�tM r
Time Cremation Completed !r ft64 6 iM �
Type of Container ,��h/?D,5d /�J�,j�,�(/�p� G/9S.E �F �n �iQjV
Remarks :
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TOWN OF QUEENSBURY
PIN,Eq�VIE} WppCEttdM� ETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804 <#-3
Phone(518) Crergat9rium,,745-447T(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:
Charles Terrell Male
(NAME) (SEX)
P.O. Box 28; Loveland Rd, Athol, New York 12801
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 7th day.of February 20 01
at His hone - PO Box 28; Loveland Rd, Athol, NY 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
Mrs. Martha Terrell P.O. 'Bok'*28; Loveland Rd, Athol, NY 12801
Relationship to deceased Wife
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT
I represent that to the best of.my.knowledge, the deceased Whas no pacemaker in his dMW
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�prematedrremains; 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 as directed, whether
s ch ims or demands are or are not wholly groundless, false or fraudulent.
3§09 Main St. , Warrensburg, NY 12885
(WITNESS) ";(ADDRESS)
a,� (4, • 0. Box 28, Loveland Rd. , Athol, NY 12801
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
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Signed on this date: 02/07/01
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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 Funeral Director
If pulverization of cremated remains is requested, check here R
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for crematicis 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 dispos'}ion 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 Oy reason of or connected with the cremation of said
remains and/or disposition of U4 remains as.directed,whether such claims or demands are
or are not wholly groundless, fa4w 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 beft.,a the remains will be accepted.
6. Unless other arrangements are made the cremated remains will be mailed via Registered
U.S. Mail within three diays"Of cremation to the funeral home handling the service. There will
be a $20.00 charge for this'service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to 12 months)$75.00
* Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations dore on Saturdays will be charged the additional$50.00.