Roche, Elizabeth TOWN OF QUEEVBU_r�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '4z .xA�r�,��
Name_ ,� r �,I! � �� i� Case #
Date of Cremation 0-2;J10/
Time Cremation Startedi l/
Time Cremation Completed ;ut P/M r
Type of Container _C I��J��'/ri 31F9' e_197 �
Remarks :
oZ% ,c9/Ivl ►
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crerrlat;9riwm-r745-4477;(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:
Elizabeth M. Roche Female
(NAME) (SEX)
F �.D�oxm�(� Stony Creek N.Y. 12878
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 12 Th... day of March 20 01
at Glens Falls,Hospi,t4l, 102 .Par�, St. , Glens Falls, N.Y. 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
Mr. James Hutchison' ='319 Valley Rd:', `Clifton, New Jersey 07013
Relationship to deceased--!- Brother
Name of Funeral Home Alex ander Funeral Home Inc.
IMPORTANT
I represent that to the best of.my:knowledge, thp,deceased...46M has no pacemaker in ffim her
body. (CIRCLE ONE)
I certify,that I havejhe,full:pqWeCand a4t]aQ izatiq -19;gr�ang for,,,Oe.cremation of the remains and
to direct the.disposition,pf;#J rer alQ.Cyr, inS;;t ateny.-,pe(0gnaI 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
ainst them by reason of or.connected with the,cremation of said remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
John. ,S..., Alexander -,3809.Main St. , Warrensburg, NY 12885
(�WITN SS) (ADDRESS)
319 Valley Rd. , Clifton, NJ 07013
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: March 12, 2001
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 cremated remains is requested, check here
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. Prearrangement
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 destroy.ed.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 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 done on Saturdays will be charged the additional$50.00.