Loading...
Herold, Walter , rf-ncWN 0F QUEEN5B21 KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEEI SBURY, :v'EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director &/Rjf� Name 42aZ j�&�� 12 Case # 6/3 -3 Date of Cremation Time Cremation Started c Time Cremation Comoleted Type of Container /- ���/� � Remarks : . , i9. n19 Al E ,3 �'��/y ,M TOWN OF QUEENSBURY • PINE VIEW CEMETERY i 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: Walter Herold (NAME) (SEX) 598 North Broadway, (STREET) (CITY) (STATE) P CODEyu who died on 5 day of December 2001 at Saratoga Hospital 211 Ch R+-gaaL i SS NY_ 17R66 (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Joyce Herold , 598 North Broadway, Sara_ York, 12866 Relationship to deceased Wife j Name of Funeral Home William J. Burke & sons Puncara7 u,+me IMPORTANT I represent that to the best of my knowledge, the deceased has c�has no pacemaker his r 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 suc ims o t,r dema ds are or are not wholly groundless, false or fraudulent. , . William J. Burke & Sons Noith way T ) (ADDRESS) aratoga Springs,New York 12866 G 8 584-5373 (SIG ATURE OF RE TIVE OR Lt9AL RV-. AN ADDRESS) Signed on this date: �DDU�- DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as foll8f Mail to Burke Funeral Hnme wi 1 1 i; Ck u Other arrangements-please specify: If pulverization of cremated remains is requested, check here xxxx 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 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 $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.