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Andrachik, Victoria rroWN OF QUEENs5BUr�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name L*6t Case # 02 Date of Cremation /—/ QZok-�F a Time Cremation Started ��/,(,j--�! "M I Time Cremation Comoleted lm c d52 /�rJy1i Type of Container C ��� � o� X�• Cy95.�d� �J7FUiy� Remarks : gyp' d 191nI ' � � 3 �� fM � 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: At C, A it 141v2gA C #I L (NAME) (SEX) / I # 4')h &�/ ' iAtx�JV (STREET) (CITY) (STATE) (ZIP CODE) who died on /'- /(-� day of 20 OoZ� ate ,g' f Cr (PLACE) (ADDRESS) ��— Name and address of nearest living relative or name of person authorizing cremation: !�ZA412 Aso 5 Relationship to deceased���zff'06A Name of Funeral Home 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. I (WITNESS) (ADDRESS) j (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: j 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 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. Af York 'Ir2935 Call 24 Hours: 516-594-7500 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: ER Female Victoria Andrachik ❑ Male (NAME) 114 Wawbeek Ave, Tupper Lake, NY 12986 (S�T SET-CITY-STATE-ZIP CODE) who died on the day of IJ6'1 dOf a the age of 1 represent that, to the best of my knowledge, the deceased has no pacemaker in his or her body. DISPOSITION OF CREMATED REMAINS i I hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if necessary, and to dispose of the remains as follows: Mail to: Rennell Funeral Home, Inc. (FUNERAL DIRECTOR OR FAMILY) 24 r1l i ff Ave, Tijpper Lake, NY 12986 (STREET-CITY-STATE-ZIP CODE)Other Arrangements- i (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 are or are not groundless, f — udff t. 9;_,� WITNE rSIGN.AT IR O RELATIVE OR LEGAL REP. s sis�e FUNERAC DIRECTOR RELATION TO nFC-EASED OR AUTHORITY TO SIGN 24 Cliff Ave, Tupper Lake, NY ADDRESS ADDRESS September 2 97 19 i 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-- j planted in his or her body. If any pacemaker was implanted, it must be removed before the body is delivered for cremation. ,�t r 11 l- • E.F. "Pete" Drown, President , 0 P.O. Box 163, Ellenburg Depot. New York 12 :-�- 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: 11 Female Qi etnri a Andra _hi k ❑ Male (NAME) 114 Wawbeek Ave, Tupper Lake, NY 12986 (STREET-CITY-STATE-ZIP CODE)who died on the day of JG/t✓A/ r '�v 261 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: Rennell Funeral Home, Inc. (FUNERAL DIRECTOR OR FAMILY) I 74 r1iff Avw, Tupz Pr T.akp, NY 1 298F (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, f fraud nt. /Ij� WITNES SG`N T R IS O RELATIVE OR LEGAL REP. FUNERAL DIRECTOR RELATION TO nFC:EASED OR AUTHORITY TO SIGN 24 Cliff Ave, Tupper Lake, NY I ADDRESS ADDRESS September 2 97 19 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 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 is delivered for cremation. Name _ ___—_ — Case 114umbef Date of Cremation _ _— 19 A.M. Time Cremation Started -___ P.M. A.M. Time Cremation Completed _ P.M. 'T-yne of Container Remarks: Signature of Operator -TV �• • • E.F. "Pete" Drown, President ' P.O. Box 163, Ellenburg Depot, New York t1 - Call 24 Hours: 518-594-7500 AIYTHORITY 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: Ek Female Qictoria Andrachik ❑ Male (NAME) 114 Wawbeek Ave, Tupper Lake, NY 12986 (SIRE ET-CI TY-STATE-Z I P CODE) who died on the day of ����'� ,c �"a_1 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 hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if necessary, and to dispose of the remains as follows: Mail to: Rennell Funeral Home, Inc. (FUNERAL DIRECTOR OR FAMILY) 24 Cliff Ave, Tanner Lake, NY 12986 (STREET-CITY-STATE-ZIP CODE) Other Arrangements- (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 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, 1 fa or f�udylgnt. J WITNE SIG�A NTL�RE7.OF�' RELATIVE OR LEGAL REP. FUNERAL DIRECTOR RELATION TO DFCEASED OR AUTHORITY TO SIGN 24 Cliff Ave, Tupper Lake, NY ADDRESS ADDRESS September 2 97 . 19 I 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 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 I is delivered for cremation.