Mullins, Irving TO`RN OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :vMW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorAM ; 4 —ro/q
Name Y /1�G- (f�( /� Case # / � 3
Date of Cremation / ZL— O2 y' 2dQl
Time Cremation Started
Time Cremation Completed
Type of Container XDI e," 5 (:n PIZ'fJi'9/Y
Remarks :
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11/23/2001 FRI 11:38 FAX 715 4474 TOWN OF QUEENSBURY CLERK 0 001/001
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804 (p
Phone (5-18) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
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:
(NAME) (5 )
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20
at C< t) � 1 F d,'C k l P N T-D v 4 / u
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
10,
Relationship to deceased_ 7-
Name of Funeral Home /'�-T-o 'J �� /' � �� 0
L
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 personat 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:
1
11/23/2001 FRI 11:39 FAX 7.15 4474 TOWN OF 9UEENSBURY CLERK 001/001
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
. 1
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.
h
Whispering Maples Memorial Gardens Inc,
ET ''Pete'' Drown, President
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.)
hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains of: q jr ❑ Female
Male
(NAME)
e es u/) e 2 9, L
(STREET-CITY-STATE-ZIP CODE)
who died on the day of , 19 , at the age of
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
I
(PLEASE SPECIFY)
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 clolrns and demands for liabilities,
losses and/or damages which may be made against them, or either of then,, by reason of, or
connected with, any action taken by them under the obove Authority to Cremate and/or Dis—
position granted and directed by me, whether such claims or demands ore or ore not groundless,
false or fraudulent.
WITNESS SIGNATURE OF RELATIVE OR LEGAL REP.
P Y- / F�
FUNERAL DIRECTOR RELATION TO r)FCEASFD OR AUTHORIRITTY TO SIGN
J
ADDRESS ADDREfSS
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 InqulneS 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.
Name Case Number
Date of Cremation _ 19
A.M.
Time Cremation Started P.M.
A.M.
Time Cremation Completed _ P.M.
Type of Container
Remarks:
Signature of Operator