Blake, Myrtle �O RN OF QUEEVBUJKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name�/e-r,(� ,�/9�f� Case # ol �(Q
Date of Cremation aWl
Time Cremation Started zQ 14-4� -d f/d I
Time Cremation Completed /v2 Pw�o ffM t
Type of Container OW R Gj60i5'Q/---
Remarks : /
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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:
Myrtle A. Blake Female
(NAME) (SEX)
151 Division Street, Saratoga Springs, NY. 12866
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 22 day of April 20 01
at Saratoga Hospital , 211 Church St. , Saratoga Springs, NY, 12866
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Lt-wis Blake Jr. 151 Division St. , Saratoga Springs , NY, 12866
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 has o 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 da$Rg&W,�A ednade
against them by reason of or connected with the cremation of said rgf �21 ether
such claims or demands are or are not wholly groundless, fa l t tods 66,Now York 12866
(518) 584-5373
(WITNESS) (ADDRESS)
� V Cr/Z 151 Division St Saratoga Springs NY, 1286E
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: April 23, 2001
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows:
Mail to Burke Funeral Home will pick up
Other arrange;nents ;,ease specify:
If pulverization of cremated remains is requested, check here_xxx
POLICIES, RULES AND REGULATIONS
1. The creme tone �.�.viil be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. N . Ho;.�jU rs or Sundays, arrangements can Le made for Saturday. Prearrangements
by telephone fog acceptance of remains is necessary.
2. Pine View Crer aicrium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensoury.
3. An authorizatio.r, for cremation properly signed by the nearest next of kin or other authorized
person stating teat 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 \ iew Crematorium from any and all claims and demands for loss or damages
which may be re,ade against them by reason of or connected with the cremation of said
remains and /or cisposition of said remains as directed, whether such claims or demands are,
or are not wholl,; 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 mus 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 t 4cre the remains will be accepted.
6 Unless other a= ,jlgements 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.
CremVt 4ni,F fir r}istra;ton•.Costs and Recording Fee: Adult$225.00 Children (age 13 months to
:�k"r�;}r�ars) 5�,�5?OA,,�nxaptSil�tx�rn to 12 months) $75.00
Additional $50.0(, cr,arge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done as, :aturdays will be charged the additional $50.00.