Wilson, Betty ri-o q+N OF QUEEN.5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, MEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�(���(' ✓
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Name Q Case #
Date of Cremation '1` o2�do2
Time Cremation Started <? o 02 ! /'g rM f
Time Cremation Completed 1 tc /O 'd /M1
Type of Container
Remarks :
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FILE No. 325 04/04 '02 07:30 1D:MED1CAL EXAMINERMG -- 941277501717 PAGE 1
Cremation Authorization
Yew 2002
Autherl utioe Number: 01052 G
Authorlutlon Date: 04/03/2M2 tie„
Requeated_By: FAX
Funorgl Horns: Batman Fanatal Servke
L ost_Nwme: WILSON
First Name: BETTY LOU
Middle Name:
Age: 48
Ruw Wbite
Sea: F
Date *f Lkutb: 03/31/2002
place-of-death; ER/Outpatient
MC Cron reference:
Cauae(e)_ot Aeath: GR ARRI:.ST,VALVULAEL HEAitC OISEASB,OM,HYPERLIPIARMIA
Condlacne:
SIVIULF41108n: SAREEN
Cremation Autborlaed By: DR.RESECCA HAMMTON
Authorization_leaucd_Uy: CAROLYN MAJOR
Faxed: 04/034DO2
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: wl
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.
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) ti (SEX)
e4w GN -N• 1"7' Jir-�
(STREET) (CITY) (STATE) (ZIP CODE)
who died on J7 S day of IWA52;1- 20je_:!1
at P� L /�'��D c 72, ?' ZJy s "e=L/I
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
5P1Z A4 ,5 /V
Relationship to deceased D
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge,the deceased has o as 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
dr—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 clai 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: y/�9 -