Clark, Ruth . TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �� �� /�
Name TH Ci / � Case #
Date of Cremation J — 3 — aoc 02
Time Cremation Started rye /9/M
Time Cremation Completed �ri 191M1
Type of Container_ = � n
Remarks : _.
'47% yy
TOWN OF QUEENSBURY r
PINE VIEWCEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium •745-4477.(if no answer)
Cemetery 7454476
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:
Ruth G. Clark Female
(NAME) (SEX)
1062 Schroon River Rd. , Warrensburg, New York 12885
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 6th day of May 2002
at Fort Hudson Residential Health Care Center, Fort Edward, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative.or name of person authorizing cremation:
Matt E. Clark, 187 VanGuilder.Rd. ,, Chestertown, NY 12817
Relationship to deceased Son
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT
I represent that to the best of.my.knowledge, the deceased RW&has no pacemaker in XW&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:tha oremated: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 connected with the,cremation of said remains as directed, whether
su claims r e nds ar or are not wholly groundless, false or fraudulent.-7 kid Daniel J. Gravel, Main St. , Warrensburg, NY 12885
(WIN SS) (ADDRESS)
vUI Matt E. Clark, 187 VanGuilder Rd. , Chestertown, NY 12817
(SIGNATUR F RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 05/07/02
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. Prearrangements
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 destroy.ed.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 di3ys'bf cremation to the funeral home handling the service. There will
be a$20.00 charge for this'"service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants(stillborn to 12 months)$75.00
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.