Kucinsky, Walter TOWN OF QUEEN
,s5BU.�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Szjfi/(,�"
Name /9,(.I� X ,�('C 2 6A V Case #
Date of Cremation
Time Cremation Started A n/1 ,
Time Cremation Completed -3f' /4c p/M t
Type of Container 5#1110�P 4!7-
Remarks :
10f ng
10
TOWN OF QUEENSBURY +
PINE VIEW CEMETERY
G CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
` Cemetery 745-44,76
k:
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 Kucinsky Male
(NAME) (SEX)
73 Pepper Tree Place, Ballston Spa, NY 12020
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 27 th day of February 20 og
at Welsey Health Care Center , Saratoga Springs, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Jean McCudden Kucinsky, SAME AS ABOVE
f
G
Relationship to deceased Wife
F
O/
l
Name of Funeral Home Wi l laim J. Burke & Sons
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has no acemaker 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
Grematorium 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
su claim or demands are or are not wholly groundless, false or fraftlIftli i J. Burke & Sons
628 North Broadway
� �— 66
(WIT S) RESS) (518) 584-5373
73 Pepper Tree Place B nSpa,NY
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
this date: Feb. 27 , 2002
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: ;56gkE /s C�'J GG
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
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."
Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
�4n 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
agave either been removed or may be destroyed and agree to protect, defend and save
�iarmless Pine View Crematorium from any and all claims and demands for loss or damages
vhich may be made against them by reason of or connected with the cremation of said
amains and/or disposition of said remains as directed, whether such claims or demands are,
are not wholly groundless, false or fraudulent. This authorization in addition to a regular
I
rial permit must accompany the remains.
4. '\II 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
ac,::epted.
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 month
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 F
Cremations done on Saturdays will be charged the additional $50.00.