Finley, Audrey rl-O WN OF QUEEN,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
�c Funeral Director A/
Name fJ Case #
Date of Cremation
Time Cremation Started `t<oc
i
Time Cremation Comoleted e ZO F/M r
Type of Container� 49 ��/� G �
Remarks :
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w TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
-> �J
(NAVE) I (SEX)
(STREET) (Cl" (STATE) (ZIP CODE) /a�93a
who died on e Jo day of / -e C 20 O/
at� lqor/Ice L4P i Nle-
(PLACE) (ADDRESS
Name and address of neartist living relative or nar-ne of person authorizing cremation:
Relationship to deceased SO/)
Name of Funeral Home /`% i 1 T c) Al' /V/v e r, Ile /,i e 2 e'
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker 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.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to �i 2 /l/l 7� /� /�� /y C/f' llo�
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. 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.
Whispering Maples Memorial Gardens Inc.
P.O. Box 163. Ellenburg Depot, New York 12935
Call 24 Hours: 518.594.7500
AUTHORITY TO CREMATE
(This Authority signed by the proper relative or legal custodian of deceased, together with
Burial Permit, must be filed at the office of Whispering Maples Memorial Gardens Inc., before
cremation may take place.)
I hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains of: (0 Female
❑ Male
(NAME)
(ST EET-CITY-STATE-ZIP CODE)
who died on the ��.t day of t , 20,2�, at the age of
I represent that, to the best of my knowledge, the deceased has no pacemaker in his or
her body.
DISPOSITION OF CREMATED REMAINS
I hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if
necessary, and to dispose of the remains as follows:
Mail to:
(FUNERAL DIRECTOR OR FAMILY)
(STREET-CITY-STATE-ZIP CODE)
Other Arrangements-
(PLEASE SPECIFY)
I
I certify that I have full power to give the above Authority to Cremate and to direct the
the above Disposition; and I agree to protect, defend and save harmless Whispering Maples Mem—
orial Gardens Inc. and the Funeral Director from any and all claims and demands for liabilities,
losses and/or damages which may be made against them, or either of them, by reason of, or
connected with, any action taken by them under the above Authority to Cremate and/or Dis—
position granted and directed by me, whether such claims or demands are or are not groundless,
false or f audulent.
ALA �• ��
,,��//W�ITNESS SIGNATURE OF REL�ATIVE OR LEGA EP.
L7(Y� t /qG ,,)A
FUNERAL DIRECTOR RELATION TO nFC EASED OR AUTHORITY TO SIGN j
.moo ���G xj o s, //1 . /�z �s/�' �T 1_1 ( ;(,-
ADDRESS ADDRESS/
20
Note: All Cremains are returned in a plastic bag in a cardboard box unless other arrangements are made.
Important: The Funeral Director should make adequate inquiries of the dececsed's medical
doctor and relatives and any hospital involved to assure that deceased has no pacemaker im-
planted in his or her body. If any pacemaker was implanted, it must be removed before the body
is delivered for cremation.
44
Whispering Maples Memorial Gardens Inc.
R.O. Box 163. Ellenburg Depot, New York 12935
Call 24 Hours: 518-594-7500
AUTHORITY TO CREMATE
(This Authority signed by the proper relative or legal custodian of deceased, together with
Burial Permit, must be filed at the office of Whispering Maples Memorial Gardens Inc., before
cremation may take place.)
hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains of: X Female
C1 Male
(NAME)
�tu or
(STRVEET—CITY—STATE—ZIP CODE)
-who died on the day of 20 0 at the age of
represent tjjg� to u the. bkt of my knowledge, the deceased has no pacemaker in his or
her body.
DISPOSITION OF CREMATED REMAINS
hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if
necessary, and to dispose of the remains as follows:
Mail to: (FUNERAL DIRECTOR OR FAMILY)
(STREET—CITY—STATE—ZIP CODE)
W�A'T
Other Arrangements.
(PLEASE SPECIFY)
certify that I have full power to give the above Authority to Cremate and to direct the
the above Disposition; and I agree to protect, defend and save harmless Whispering Maples Mem—
orial Gardens Inc. and the Funeral Director from any and all claims and demands for liabilities,
losses and/or damages which may be made against them, or either of them, by reason of, or
connected with, any action taken by them under the above Authority to Cremate and/or Dis—
position granted and directed by me, whether such claims or demands ore or are not groundless,
false or fwudulent.
T NES& SIGNATURE OF RELATIVE OR LEGALXEP.
FUNERAL DIRECTOR RELATION To nFCEASED ORAUTHORITY TO SIGN
/ 7-9 AZ& _a
_
ADDRESS
RESS
— 2 — . 200Z
Note: All Cremains are returned in a plastic bag in a Cardboard box unless other arrangements are mode.
Important: The Funeral Director should make adequate inquiries of the deceased's medical
doctor and relatives and any hospital involved to assure that deceased has no pacemaker im-
planted in his or her body. If any pacemaker was implanted, it must be removed before the body
ic Jalivarorl fnr cremation.
Name _. _ _ Case Number _
Date of Cremation . 20
A.M.
Time Cremation Started P.M.
A.M.
Time Cremation Completed _ P.M.
Type of Container
Remarks-.
Signature of Operator