Francis, Juanita . TOWN OF QUEEN,.,5BU1ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NI EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 'L'-iA-i
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Name ��j ,�1(j� /S Case #
Date of Cremation J— o?. "671
Time Cremation Started
Time Cremation Completed -30 f/M I
Type of Container
Remarks : R
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804 '
Phone(518)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) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT
1 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
Ematorium 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
Other arrangements - please specify:
If pulverization of cremate 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 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.
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 $100.00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100.00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
Whispering Maples Memorial Gardens Inc.
E.F. "Pete" Drown, President
P.O. Box 163. Ellenburg Depot, New York 1 2935
• 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: ® Female
Juanita S. Francis ❑ Male
(NAME)
South Little Wolf
(STREET-C TY-STATE-ZIP CO0
U
who died on the13 day of //
RC/ ,*9' , at 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 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 Cl '
(STREET- ITY-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 &rrands are or are not groundless,
fal a or fraudulent. - 1] `' f9a
v
WITNESS SI NATURE OF RELATIVE OR LEGAL REP.
NERAL DIRECT R RELATI TO DECEASED OR AUTHORITY TO SIGN
ADDRESS 3 ADDRESS
. 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.
Whispering Maples Memorial Gardens Inc.
E.F. ''Pete" Drown, President
P.O. Box 163, Ellenburg Depot, New York 12935
Call 24 Hours: 518-594-7500 s • •
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: ❑ Female
❑ Male
(NAME)
f3 . -,r I n t
(STREET-CITY-STATE-ZIP COD
O '
who died on the/ day of f�f �%� , fig at the age of fG� --
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)
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 _emands are or are not groundless,
false or fraudulent.
fZ't� i ,'n_._.-, f.-Zii.� f ✓" .(._,.• rt _ (. }'� r <_,
^' WITNESS SI NATURE OF RELATIVE OR LEGAL REP.
UNERAL DIRECT R RELATI TO OFCEASED OR AUTHORITY TO SIGN
r1 y ply ,r '���'f
ADDRESS ? )ADDRESS
is-
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 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
s p e*4 Ma�les Memortat Gardens Inc.
�
�.F. "Pete" Drown, President
P.O. Box 183. Eltenburg Oepot, 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: ® Female
Juanita S. Francis ❑ Male
(NAME)
Litt 1r, '11ol-f Pd. Tunner Lake, 1fY 1 ?«fi0;
(STREET-CITY-STATE-ZIP COD
/3 � o� .
who died on the day of /1 i , +9—, 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: Pennell Funeral gorge, :Inc:
(FUNERAL DIRECTOR OR FAMILY
I . Cliff Ave. Timper Lake, p1Y 12gR6
(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/for Dis—
position granted and directed by me, whether such claims or demands are or are not groundless,
false or fraudulent.
WITNESS SI NATURE OF RELATIVE OR LEGAL REP.
FUNERAL DIRECT PR RELATI TO OFCEASED OR AUTHORITY TO SIGN
-r A
�y r � �� K--r ,I,e 1%7
ADDRESS ADDRESS
3 3 � tea--- 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.