Musser, Helen TOUN OF QUEEVBU. ;y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Time Cremation Completed
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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 Regulations to cremate the remains of:
Helen E. Musser female
(NAME) (SEX)
4 Meadow Lane Saratoga Springs, NY 12866
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 11 th day of April 20 01
at Wesley HCC Saratoga Springs, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Richard J. Musser same as above
Relationship to deceased husband
Name of Funeral Home William J. Burke & Sons Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased Kapm has no pacemaker in his or her
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
against 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.
Saratoga Springs,
L %✓. �'1Z— 628 North Broadway NY 12866
(WITNESS) (ADDRESS)
same as above
(SIGNATU E OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 14 Apr 01
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-;Tease specify: Burke will pick up
If pulverization of cremated remains is requested, check here xx
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 Queensuury.
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 V ,-rj Crematorium from any and all claims and demands for loss or damages
which may be m.a,,e against them by reason of or connected with the cremation of said
remains and /or d sposition of said remains as directed, whether such claims or demands are,
or are not wholly oundless, false or fraudulent. This autt;orization in addition to a regular
burial permit mut accompany the remains.
4. All remains muse r e encased in a casket or suitable alternate container. Caskets and
containers must oe 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 bescre the remains will be accepted.
S. 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.