Carlson, Albert �o WN of QUEEVBUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1,'_. � l� 2Y Case #
Date of Cremation 7`
Time Cremation Started .37-- /9/M
Time Cremation Completed Zt"<X5 f N)J
Type cf ContainerC � ,�'i9��
Remarks : `-� -
i
i
TOIl*iNSI3t,�RY
Fu
I=MATORIUM"
Newyork 12804
Winolanswer)
Y " C,artery`745=4476
.... .......-.•.ww+.v:ewdNdiY.F'!a..... .. ..:iti:0/ii.:l4""»...,.'...,_'. ..
:AUTHO' I aON TO CR MATE
The undersigned reques z
�iaw Crematorium, in accordance with and subject
to its Rules and Re ultions�fo•,.cremate ains o
a ft.;•,'y
. ...._.q. ,.
(NAME) (gam)
(STREET) CLT1 `(STATE) (ZIP CODE)
who died-on_. �.. r �`: ayy»�# {, ..w_ j:. 4_E ;20
at
(PLACE) '' (ADDRESS)
•ifY '�.' .�i�.1 t'7iJ++�'y'�{ :Sixv'.��jtl�.Jy°.#'44L`rr:l.• .�'�M1i'F..y...•';-
Name and address of nearestliving:relatii elormame of person authorizing cremation:
/,�!*•,; ... '�'��f t ?'sE..•�i,t3 �r .` ,1`,�:�t `' i'�=l1�dc:'Y'i:a-'� .. -*;
,>f;rT..x:+,ar,,:�� ,�y' ,yth��-9;;'•.a.' ,r.;,i- .,
.,, ::!t':wFi':°..�°k�:•:�.:iiY+S,."i... -toaiiitt'�'.y�,`�1.: �S*�.> ,;tit�fltl
• .• .t ��1l�'L, .XW -', _ '.fu',�„:i�'r':�,: R }5'7;.'Itt 1T..;..;�..x_.. . ^.l
Relationship.to::dacsal
Name of Funeral HomeX'/r!w✓ 2G-� C 4n,rY�
- ,..,•..•+.:ii �....t.di'+1•14Gr 'i'�-:r t�.'�t•• 0 !..,Y'atS•ro',r.4':. . . - ..
IMPORTANT w,.
I reprewnt..
body. (CIRCLE ONE)b � no pacerrte ttis or her
` 4,1 f, matio f:the remains and
to,dir..eotthit-kwive either been
removed Wdo, „harmli6&ine'View
Crematorium from any and.:a(;cli aad ands.for loss.ordamages which may be made ,
ai th by-raaspn:oft: o Igpe �vy t)a,cfematipn.of-said remains as"directed, whether
such c s or demands are or are noo/tw .,ly gfoundless.ifalse•or.fraudulent.
a�
ITNESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: :2 1-7 o
DIP,,4SITIQN tgPrX AINS
I hereby direct Pine View:Cr6aiatonum to"dispose"of the�"cremated remains as follows:
Mail to
•ram-i'.,i..,
Other arrangements-please specify:
.-If-pulverization of crematedr igs is.req ,,oheck,here
'RI,C�I,ES; ND�R1S`AEGLII:ATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M. Monday-
Friday. No Holida�rs or•�u d s�., Tf.gGgQ netits.c �@•.�ta_de for Saturday Prearrangements
by telephone for acceptance of remains s necessary.`
2. - Pine View Crematorium:isIQcated epiooNiew.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.khej� .ih :the:pa*iihdtauthorityito`arrange for the cremation of the
remains and to direct the disposition of:the,cremated'remains, that any personal possessions
have either been rerr�p AW b ( jarWto protect defend and save
harmless Pine View Crema>orwm from any and..alf6laims and demands for loss or damages
which may be made aginsf tHem by red on•of.:or connected with the cremation of said
--' -rernains and/ordismjtjQ44P.W.rmoin 110000A3Nhgtber such claims or demands are
or are not wholly groundless;jalse or fraddulent. This authorization in addition to a regular
burial permit must accompany the remains:
4. All remains must be encasedjn a casket or,suitable alternate container. Caskets and
containers must be of combustible material. .No Styrofoam or plastic containers will be
5. The.
qule ion relati eag cardiac pac6makprs must.be answered on the authorization to
crerrlate before the remains will beaccepted.
Unless'o" r arrangementsafe-madeyNOcremated'remains will be mailed via Registered
U-Z M*Il Vithirj-'three da` '"
y. ` 'cretYiatfoo'thefuneral home`handling the service. There will
$2U.00`charg 8 yt
�. ,,.
l - e a e'f,drAh
Cremation;AdministratioWCoc#stand Recording,,Fee,,,�Adult$225.00 Children (age 13 months to
12 years)$115.00°•Infants*(stilltiom`to`1Zinonths)°$75 00 ,..
" Additional$50.00 chargg�f r.&ramations.done after 3:.00..P,M.,.Monday through Friday.
Cremations done on Saturdays will be charged tfie'additional$50.00.
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