Grimm, Emil . �O WN OF QUEEMs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Jgi�,�Xi4
Name Case # 9123
Date of Cremation
Time Cremation Started
Time Cremation Completed i+QIM i
Type of Container c.. o/ ,692"D ��✓' /� (:/TJ,�OI� `Tj� ,91�
Remarks : � '—
DISPOSITION 0 , a. TED REMAINS
o
I hereby direct Pine View Crematorium to c gfthe'cremated remains as follows:
Mail to
Other arrangements-please specify: - < '
If pulverization of cremated remains-is requesteid,lcheck here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for crematigns,5,days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. No Holidays or..Sundays;:,arratt gxs'dan,be made for Saturday. Pre-arrangements
by telephone for acceptance of remains W,necessary.'
2. Pine View Crematorium is located on.thEWIU,gs of the.Pine View Cemetery, Quaker Road,
Town of Queensbury.
3. An authorization for crematio ,properly;s' b .ahe„nearest next of kin or other authorized
person stating that they::ditfic�:potir uthRrto;arrange for the cremation of the
remains and to-direct fi the-I' '" aiFts, that rsor ns Pestian-fl. ,�
have either.been removed,,�r. Y " ' ree to,protect, defend and save
harmless Pine View Crematorium from any nd`-al1`claims and demands for loss or damages
which may be made against'them by reasaon,of or connected with the cremation of said
remor aae not wh/ollroundlet ssf7e oefra4 d,uenis auth whethersuch claims or demands are,
P
y g onzation in addition to a regular
burial permit must accompany the remains.:
4. All remains must be encased'in a casket ,.,,Suitable alternate container. Caskets and
containers must be of combustible matenal1'�No*rofoam or plastic containers will be
accepted.
5. The question relative to cardiac pacema,, ;must be answered on the authorization to
cremate form before the remains will be pry`r '
a�
,epted.
,MFs.<"!u!;
6. Unless other arrangements'` dot elmainsy►lill=be mailed via Registered
U.S. Mail within three`day "o� a Cyr taeraIftme:handling the service. There will
be a $25.00 charge`foi+JtHi y ryvygINA'. W >F, <#
Cremation, Administration Cost$%n# d,1Recordi1 v:.Adult$300.00., Children (age 13 months to
12 years) $150.00 Infants(still 12 mom s)$100.00
Additional S50.00 chargefie cremations�e9s after 3,0"P.M.i Monday through Friday.
Cremations done on Saturdays will;be charg' a additional$50.00.
x
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM OCJ�j
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 ViewVematorium. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
Emil H. Grimm Male
(NAME) (SEX)
174 Big Brook Rd. , Indian lake, NY 12842
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 8th day of July 20 02
at his home (same as above)
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Robert K. Grimm, PO Box 544, 19 Church St. , Pheonicia, NY 12464
Relationship to deceased Son
Name of Funeral Home Alexander FH,Inc. , North River, NY 12856
IMPORTANT
I represent that to the best of my knowledge, the deceasedc 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
agains eason of or connected with the cremation of said remains as directed, whether
su claims demands are or are not wholly groundless, false or fraudulent.
Warrensburg, NY
(WITNESS) ( DRESS)
'-,�A� ��z
Same as above
(SIGNATURE OF RR I E OR LEGAL REP. AND ADDRESS)
Signed on this date: 7-- /d"'y L