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Hart, Hulda rl- L O OF QUEEN1J . KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Name D � Case Date of Cremation Time Cremation Started Time Cremation Completed le pB© /M1 Type of Container (°/9�D, ��� �j �i Remarks : Jol TOWN OF QUEEN58URY 613T PINE VIEW CEMETERY 14 sawCREMATORIUM Queenstbury, New York 12SO4 � ..,.--. Quaker Road, _ no answer --- -.._... phone ( 18) GremCemetiery7745 4476 1g AUTHORIZATION TO CREMATE ned request«' atnd authorises Ping Viaw Crematorium, in The undersig and Regulations to accordance with and subject to its Rules cremate the remains y�-Of ' A Le (Name) � � �d`�arr t6tate) (Zip Code) (Street ) day who died on ---- of tPlac > (Address) erson 'IVa:me and address of nearest living relative or name of D aremat i on a �! 14w authorizing c 10, C. (Name) Relationship to the deceased Nameof Funeral Home � c; /t .-. IMVORTAN7s knowledge, the deceased has Or 1 represent that to the best of my (Circle Ono) i has n acemaker in his or her body. I certify that I have the full power and authorization to arrange l for the arremation df the remains and to direct the disposition of ' the cremated remain$, that any personal passtssians have either been removed or may be destroyed, and agree any protect, defend and save harmless pine view Crematoriumch fro ted mmasdW against lthem lby and demands for loss o da cremation Of Or Cpnnpc with thcremation Of said remains as directed, whether such claims or demands are or are not wholly groundless, false r fraudulent. (Wi Hess) (Address) ( ignature o Rela ve or I-aPgasl Rep. and Address) Signed on this date : i � w DISPOSITION OF CREMATED REMAINS 4Wh9;y direct Pine View Crematorium to dispose of the cremated remains as/�folf lows p I� Mai 1 to T'o r4u(k.- -- /:e ,L �?j - n n. c_l 1 Other arrangements - please specify] If pulverization of cremate remains is requestedo check here POLICIES, RULES AND REGULATIONS 1. The crematorium will be open for cremations S days, a week 7s00 A.M. - 3:30 R. 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 rWmwinit and to direct the disposition of the cremated remains, that any personal possessions have either been removed or may by destroyed and agree to protect, defend and save harmless Pine View Crematorium from any and all claims and demands for loss of 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. A. All remains must be encased in a casket or suitable alternate container. Casket% and containers must be of combustible material. No styrefoam or plastic containers will be accepted. S. The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. b. Unless ether 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 Feet Adult $185. 00 Children (age 13 months to 12 years) $130. 00 Infants ( stillborn to 12 months) s` o. 00