Petersen, Alice rroTtN OF QUEEM5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /9,� �� G� J�,��i /�5,�' Case # $�
Date of Cremation � '"� / - o2(10/
Time Cremation Started 2;15� 1!9/M f
Time Cremation Completed�l
Type of Container ,Uwy
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:
Alice E. Petersen Female
(NAME) (SEX)
46 Schoolhouse Rd. Forest Dale,Vermont 05745
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 17 t h day of July 20 01
at Residence 46 Schoolhouse Rd Forest natP,VPrmnnt
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Marion Watson
Relationship to deceased Guardian
119 North Main St . ,
Name of Funeral Home Durfee Funeral Home Fair Haven,Vt . 05743
.r
IMPORTANT
I represent that to the best of my knowledge, the deceased has 01-169pacemak is or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of 39 a remains and
to direct the disposition of the cremated remains, that any personal possessions ; e either been: ;
removed or may be destroyed, and agree to protect, defend and save harmless Pi View
Crematorium from any and all claims and demands for loss or damages which maybe made
against them by reason of or connected with the cremation of said remains as directed, whether
such c s ojend's-" not wholly groundless, false or fraudulent.
Al f
(WITNESS) ( DD ESS)
( GNATU F RE/LATIVE OR GAL REP. AND AD ESS)
Signed on this date:TU'l l -2 6 u,/
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
.1
J
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. Pre-arrangements
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
rrt�t�ave 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 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--M-fernains 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
5, . Tf quesV relative to cardiac pacemakers must be answered on the authorization to
c&iAiate-for ' before the remains will be accepted.
f 6. Unless otherngements are made the cremated remains will be mailed via Registered
S. Mail wittin three days of cremation to the funeral home handling the service. There will
r' tie a$25.00 cfiarge for this service.
Ce,mation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 fears)$150.00'Infants (stillborn to 12 months)$100.00
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.