Cubley, David o OF QUEENs5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�"
Name Case #
Date of Cremation
Time Cremation Started-z"Lo /-m
Time Cremation C3moleted,3--40 pjM I
Type of Container C, ,�f?VA ���� Gj, �j� r/fj��
Remarks : G"f & �Q1F
��' o?� 1<7,, Il/Z J
b`!/l'1r• G1:r11 11:�9 ^1rS`'73�r'+1 _.1 �K.G �.v o.x�.•:rx. ..,ems -
TCUWN OF QUEEN9BURY
PINE Vll~VJ CENIETERY
3
REMATOR1UM
1��r3k8r Road• (,ueensoury '.ew York l28Cn � .
a ne 318 Crematurtum 745--4477(it no answer) V
ho )
Cemetery I45-44.76
AUTK4R17ATIQN TG CREPAA?E
The undBrS!gnesd fC(Ilvests and 111.00rizes pine View Gretnstonurn, in 8ccordance With and subleC1
to is Rules and Re9ul6itions to cremate the rerneins of'.
lt, •SFW
(NAM )
STATE! !�tP :OOE)
(STREET) (C ITY) ( /
who sled cm _ -7 ——day of
at
(,FLACE) (AJ U5)
Name and address of nearest nirg relative cr name of person autnorizing urernaiion,
-
ReWionship to deceased —"`-
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Name of Funeral
IMPORTANT acemgKer in his or her
I r4wov 9nt that to the best ct my knowledge,th.e deceased IM Or hrJs 1Q P
body. (CIRCLE ONE)
I oMtity that I have tht fu11 p ewer and at4horizeibn to arrant"for the rrermatlon of then remains and
to direct the dISPOs+bon of the crated remains, that any personal possessions have either been
re^noved or may be destroyed,and agtee to protect, defend and save nefrNe±sS Pine View
s and demands for loss or aenleges whtCh may be made
UfCnlatorturn from any and ail clafn"
egalne( ern by reason of or conn ad with the cu s
ndles,.ralso o f judifentof said rarns na s arracted.whPthe:��
S S _ d est7t Y
t TN 5)it VA
iGNATURE OF RELA V OR AL REP, .A A{?gRESS!
Signed this daite:_., ���.�-�- -- _..._
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DISPOSITION OF CR6MATEO REMAIkS
I here oC dir%ct Pine View Cremato•i:jm to disposes ef the cremates -emaau16 as'a{Icws
S�
sego to
rv� c t__ ._.1.Q-.-L�yw r,- :-
1�..—
other arrangements please s,pectly'_
v pulverization of crer ated remarfts is MQUefted,CheCK hVe _
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POLICIES,RULES AND REGULATIONS
The crematorium will be opan fir crematkons 5 days a week 7.00 A M - 3.30 p.M Monday-
Fridsy No Ho4days or Sundays, arrangements car be rr,ade tc•r Saturd Pr -arrasay g
t;y telephone for acceptance of remains is rts✓G6SSarY."
2 taints'J#ew Crennatorturri is locstod on the grounds of the Pine ViOw Cemetery.Quakor Road,
Town of Dueemsbury,
3. An 8utftorizv,6iur for:reination properly signed by the nearest next of his or at-her autnor'ized
person stating that they 10 have the power and a;rthority to arrange for tnriraanrmjit�s efsaiar+s
remains and to direct the disposition of the crerPreted remains.that any pe
have elther been removed cr mcy tie destroyed and agree to ptQtect, defend and Save
harrrtteas Pir,e View Crernatocurn from any encs all claiifIS arc demands for loss ur damages
which May be made Against triem by feason of or varnecteC with the cremation of sod
remains and for disposition of sold rrematna as directed, whether such claims or demands are,
or are not wholiy groundless, feslse ar frautlulert "his auitnorizaticn 0 sddition to a regular
burial permit njuSt accompany tr,e remains.
a All ra naMs must be encased it a cttsket or suitable
rofoa ate container
costaa ketrs and
COntojnere must be of co;combustible material, No Sty PI
be
accepted.
5. The question relat)va tc cardiac pacemakers moat be answered on the authorization to
cremate farm before the remains wsll be acct"oted.
6 t;nteas other arrangements are made the cremated r'emams wi i Do mai!+dd vFa Registered
11,S. Mail whttin threes days of cremation to the funerMl horne handing the service. 'I here will
oc a$25.00 charge for this service.
Grernation,Adrrltnistration Ccsis and Recnrdtng Fee Adult$300.00 Ch4drern(age 13 months to
12 years)3150.00 Inferrts (stillborn to 12 months)3100 00
Additipnal S50.001 Charge for crent7t�vns dome after 3:00 P.M. Morday .linrough Friday.
CremabonS done on Saturdays will bef charged the addit!cnsl S50 00,
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