Jeffords, Mary . rrnWN OF QUEEM
,5B UJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEF—NSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
"uneral Director v
Name E)I�IZ� �fi�o Case # S�
Date of Cremation
Time Cremation Started
Time Cremation Comole-ed
T
Type of Containerp �G®� Gw.s � /SeAS,E'o� T,y.E" t�i9y
Remarks :
, 1 , , m r
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
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 Reguiations to cremate the remains of:
Mary Evelyn Jeffords Female
(NAME) (SEX)
189 Broad Street Schuylerville, PdY 12371
(STREET) (CITY) (STATE) (ZIP CODE)
r
who died on S h day of June 20 01
at Saratoga Hospital Church Street Saratoga Springs,I1Y
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Edward Jeffords Sr 189 Braad Street Schuylerville, NY 12871
a Relationship to deceased Husband
Name of Funeral Home Flynn Bros. , Inc. — Schuylerville, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
no b'=t7ody. (CIRCLE ONE)
ect
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
9U 'removed or may be destroyed, and agree to protect, defend and save harmless Pine View
c�J : :Crematorium from any and all claims and demands for loss or damages which may be made
against them by r"- son of or conne d with the cremation of said remains as directed, whether
t
or a of wholly groundless, false or fraudulent.
13 Gates Ave. Schuylerville, NY 12371
(ADDRESS)
1C-9 Broad Street Schuylerville, NY 12g71
. NAT R 0 LATIVE OR LEGAL REP. AND ADDRESS)
6—S-01
Signed on this date:
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: Will Pict: UP
If pulverization of cremated remains is requested, check here Y,
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. 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 and save
harmless Pine View Crematorium from any and all claims and demands for loss or damaR f�, si
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. t�_
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. TFere writ/
be a $20.00 charge for this service. _.._,._.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children.kage_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. __