Gilmore, George r
TMIN OF QUEEN f�y
,s5BU.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director R�'
N a m e Case #
Date of Cremation �� y � 0-7
Time Cremation Started f
Time Cremation Comoleted
Type of Container `
Remarks :
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09/26/01 09:62 FAX 6184827447 KINKOS.WOLFRD. _ — _ 4002
PAGE 02
at/2-6/2001 86:36
518-684-8147 !�— — W14'
TO"05 QUEENSUORY
plNe VIEW CEMETERY
CREMATORIUM
Quaker Road.Queensbury,New York 12804
phone(518)Crematvl1um 746447T
(If no answer)
746-44TS
AUTHORIZATION TO CREMATE
The undersigned re quest,a to cremate the mVi ains of smstorium,In accordance with and subject
to its Rules and Reg
Male
GjpRGB GORDON GILMORE (3EX)
(NAME) ri,n a,0Y 12866
RCRIAY Health Care Center, LawreaCe Sbreet, Saratoga Pp CODE) 9
STATE)
who died on 24 t:h dal 4fr:r,
Sala t 2001
at Wes1eX FIe81t77 Care Cezlfi9r., r t;egA Spsic9e. NY
(PLACE)
Name and address of nearest living Mls W't*r rWr**- -Wson authorizing cremation:
Karel, Gilmore, 9 TampaAve. , Albany. 1- 12203
• _�{`{.�_ S Nr::; "ds .�+ fit' �;..'evg:.i
-Name of.EunerW Home.William J. Bunke & Soas Maera 1 Home'
IMPORTANT: a the deceased tb,o pacemaker in his or her
I represeh 1bat to the best of Itiy knowledg .
may. (CIRCLE ONE) n,
Irterrrairl`S and
n fi'C"'t,att ttavrr ttie tall-ppWrer and authorizatftS 14 n a" 'ttI!CI a6I i 6tds
to direct the disposition of the cromated remains.that any personal possessions have either been
�tsdagtee.to 0rtSg&4*nd*XI'seWp*arrrl Ws Pine View
agal 't sin by reason of or Bonn 'Ma`Qth the cremation of said remains as directed,whether
such maims or demands are or are not whallY groundless,false or fraudulent Y�rke a
�I�PondMoa�1
..i ga Springs.
Ta a v i3E$w °:,.� �. Ritt3}f4'6 .,..._.__.
OF E OR LE A 'REP.AN0 ADDREsy)
Signed an this date:
rb iw;
�t 1" rR �;t''V".r:ti h;Q,.St?S ';P'is ®I
�d tl1Y&°j$w i;GirRC25itli7r of trte:r� 7�>ed (��!*i�i6;S, u'dt E:..y
anrvarJuca[1 of lY1dY i;,iC destroyed,ar,a agree to crotectra$f9r1d 4rd
rlart.�e Sawh h may``:Q•f adr
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
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. Prearrangements
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
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 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. All remains 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
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
6. Unless other arrangements 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.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants (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.