Thayer, George Sr. rl-nWN OF QUEEM
5B 21.E
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorLo �' �
Name Case #
Date of Cremation �' —
Time Cremation Started � t ZQIM +
Time Cremation Completed' i /�/4r/v ) I
Type of Container � 2'71 2! y
Remarks : i�
�71s�:;-Ii4 nn
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 s located on
Queensthe grounds of the Pine
View Cemetery, Quaker Road,
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, o fraudulent.
accompanyatheoremainsn rizatio in
addition to a regularburial Permit must
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 �materdiac form bpacemefore ers the mrema iust ns will rbe
ed
c , the authorization to
accepted.
6. Unless other arrangements
are made the cremated remains will
be mailed via Registe
red 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
0 char a for cremations done after 3:00 P.M.
* Additional $100.0 9be
Monday through Friday. Crma100e00t Any remains ions done nreceived yafter113.30
charged the additional $
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:
Mr. George Thayer,-4. Male
(NAME) t i (SEX)
32 Fourth Street, Fair Haven, Vermont 05743
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 12th day of August 20 02
at Haven Health Center, Nichols Street, Rutland, Vermont
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Gail Thayer
Relationship to deceased WIFE
Name of Funeral Home Durfee Funeral Home, Inc.
IMPORTANT
I represent that to the best of my knowledge,the deceased 4MW as 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
matorium 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 RE TIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: August 12, 2002