Gregory, Helen rrO%N OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case # �d
Date of Cremation j — 02® o7-Qc:7 /
Time Cremation Started
Time Cremation Completed 'F!M
Type of Container�' �/1
Remarks :
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804 111
Phone(518) Crematorium,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:
Helen I. Gregory Female
(NAME) (SEX)
77 Goodnow Flow Road, Newcomb, New York 12852
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 15th day of March 2(91
at The Elizabethtown. Conmunity,,Hospital, Elizabethtown, New York 12852
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Michael Gregory — 1452 Friends T,ake 'Rd, Chestertown, NY 12817
Relationship to deceased - Son
Name of Funeral Home Alexander Funeral Home, Inc. , North River, NY 12856
IMPORTANT
I represent that to the best of.my;knowledge, the deceasedCOW&has no pacemaker in KpP1x her
body. (CIRCLE ONE)
I certify that I have,the.full.poweraand authorization to,arrange for the cremation of the remains and
to direct the disposition;o,the-,cromated::remains,thatany;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
ag inst them by reason of or.connected with the,cremation of said remains as directed, whether
ch claims or demands are or are not wholly groundless, false or fraudulent.
_ John S. Alexander, 3809 Main St. , Warrensburg, NY 12885
(WITNESS) .(ADDRESS)
Michael Gregory, 1452 Friends Lake Rd, Chestertown, NY 12817
(SIG URE F LATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: March 15, 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: Return to Funeral Director
If pulverization of cremated remains is requested, check here X
POLICIES, RULES AND REGULATIONS
1. The crem�;corium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. NJ Holidays or-Sundays, arrange;! ants can be made for Saturday. Prearrangements
by teleph:,ne for acceptance of remains is necessary.'
2. Pine Vif.w Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town r.,f Queensbury.
3. An F athorization for cremation properly signed by the nearest next of kin or other authorized
per,on stating that they do have the power and authority to arrange for the cremation of the
re nains and to direct the disposition o'the cremated remains, that any personal possessions
h.we either been removed or may be destroyed and agree to protect, defend and save
armless Pine View Crematorium from any and all claims and demands for loss or damages
hich may be made against them by --aason of or connected with the cremation of said
r.rmains and or disposition of said rE mains as directed,whether such claims or demands are.
or are not wi olly groundless, false of fraudulent. This authorization in addition to a regular
b.jrial permi must accompany the rr mains.
4. A I remains riust be encased in a c=Isket or suitable alternate container. Caskets and
containers mist be of combustible material. No Styrofoam or plastic containers will be
accepted.
5. Toe questior "elative to cardiac p icemakers must be answered on the authorization to
cremate form before the remainF vill be accepted.
6. Unless other.arrangements are made the cremated remains will be mailed via Registered
U.S. Mail within three days°'of crsmation 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.