Cooper, Lillian TOq+N OF QUEEM
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 4(� �
Name � ) % �/� non Case
Date of Cremation�'l
Time Cremation Started! &M I
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Time Cremation Comoleted
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•• + TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM o �J
Quaker Road, Queensbury, New York 12804 �j fix.
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:
L//1// Cog fit' , Fema 1 P
(NAME) (SEX)
211 Church Street, Saratoga Snrin
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 25 day of Nnvamhc r 2001
at Saratoga Hospital Nursing HomP _ 911 ehurcb qF Sa
6,prings, NY.
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs Mary Ann Giar-at , 132 Hutchins unad Ratichnn c"-,,NY, 12020
Relationship to deceased D
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased ha or has no p ce ker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization 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 as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
r� William J. Burke & Sons
NOFth Broadway
( T ESS) ADRE Saratoga Springs,New York 12866
(� 132 ` 1U1PJW R74td, Ballston Spa, NY
(SI ATU OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: Nov 26 2001
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to Frea F- C;roff , Tnr Funeral Home
234 West: Orange Street , T.anracFar , PA 17h03
Telephone 717-397-8255
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here xx
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 ` I'
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 q
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 ;r
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 $25.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $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.