McCormick, Francis rrnWN OF QUEEN,5BU-' �Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,[�IiR
Name YIJJ1�y�j � ��f��jG�' Case #
Date of Cremation ✓a� G f
Time Cremation Started Jam, i
Time Cremation Completed f/ � /0"m )
Type cf Container r &ZKOAD Jgo.,C n 7*// �
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:
FRANCIS L. McCORMICK Male
(NAME) (SEX)
812 Stone Church Rd. , Middle Grove. NY
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 20th day of July 2001
atSaratoaa Hospital,Saratoaa Springs, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Lot 8
Francis McCormick, 214 Jones Road, Saratoga Springs, NY 12866
Relationship to deceased Son
Name of Funeral Home Wi 11 i am J. Burke & Sons Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as n pacema. in,
body. (CIRCLE ONE) o
I certify that I have the full power and authorization to arrange for the cremation of toe�,-mb and
to direct the disposition of the cremated remains, that any personal possessions have 66er 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, w,.
such claims or demands are or are not wholly groundless, false or fraudulent.
( TNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:K �-3 6
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Vie.v __ rernatorium to dispose of the cremated remains a:- follows:
Mail to
Other arrangements-pleasc �pecify. Burke Funeral Home will pick up.
If pulverization of cremates remains is requested, check here XX
POLICIES, RULES AND REGULATIONS
1. The crematorium v.,Ai oe open for cremations 5 days a weak 7:00 A.M. - "J.30 P.M. Monday-
Friday. No Holidays Lr Sundays, arrangements can be made for Saturday. Prearrangements
by telephone for�,c:;eptance of remains is necessary.
2. Pine View Crem4 � nunn i,, located on the grounds of the vine View Cemetery, Quaker Road,
Town of Queenst�t;Fv.
3. An authorization :c:r 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 parsonal possessions
have either been removed or may be destroyed and agree to protect, detend and save
harmless Pine Vie,,v Crematorium from any and all claims and demands for loss or damages
---which may be mUc,e against them by reason of or connected with the cremation of said
remains and /or ,: sposition of said remains as directed. whether such claims or demands are,
or are not wholly ,.,-oundless, false or fraudulent. This authorization in addition to a regular
----burial permit must accompany the remains.
4. All remains must to encased in a casket or suitable alternate container. '2askets and
containers must ou of combustible material. No Styrofoam or plastic containers will be
accepted.
5. :4 question relative to cardiac pacemakers must be answered on the authorization to
cremate form befc,e the remains will be accepted.
'nless other arrargements are made the cremated remains will be mailed via Registered
u.S. Mail within tnr ee 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 Intants (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.