Linn, George LOWN OF QUEEN5B 1 9. Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
N a m e(:;j6 q G'FL Case # 3'
Date of Cremation
Time Cremation Started
Time Cremation Completed 'l
Type of Container
Remarks :
�� V l
TUWN OF •UUEENSUUf1Y
PINE VIEW CEMETERY
a
CREMATURIUM
Uuaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTNURIZATIUN 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:
M
Name (Sey,)
4 la"466mig /' �-?
(Street ) �c - (City) (State) (Zip Code)
who died on rl • day of U&/ •
-at f
(Place) Tr (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
AJ &4L)
(Name) Address)
Relationship to the deceased e9zmow!Oe
Name of Funeral Home 2 "le"/,C-�
IMPORTANT:
I ' 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 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 as
directed, whether such claims or demands are or are not wholly
gro dle s, fals fraudulent.
(Witness) (Address)
(Signature of Relative or egal Rep. and Address)
Signed on this date : �(/�
7ys= yy?y
DISPOSITION OF CREMATED REMAINS
I hereby direct . Pine . View Crematorium to dispose of the cremated
remains as follows :
Mail to �i` G -40
•
Other arrangements = please specify :
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium wi 1 1 b.e open for cr•emat,ions 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, Uuaker' Road, Town of Q ueensbury.
3. An authorization For cremation properly signed by the nearest
nest 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
remains. must accompany the
4. All remains m;!_t ' br en..ased in a catket or Suitable alternate
container. Caskets and containers must be of combustible
material. No styr:afoam or plastic containers will be accepted.
5• The question relative to cardiac pacemakers on the authorization to cremate form before must be answered
the remains will be
accepted.
6• Unless other arrangements are made the cremated remains will
to the funeral home be mailed .via Register
ed U. S. Mail within three days of cremation
rns handling the service. There will be a $20. 00
charge for this service.
Cremation, •Administration Costs and Recording Fee: Adult s185. 00
Children (age 13 months to 12 years) s1]
to 12 months) •0. 00 Infants ( stillborn
s70. 00
e
TOWN OF OUEENSouny
..P 1 M VIEW CkMETERY
a
CREMATOR I UM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or, if no answer
Cemetery 745-4476
AUT140111 znT Z ON TO CREMATE
The undersigned requests and authorizes. Vine View crematorium, in
accordance with and subject to its Rules and Regulationsto
cr9pate the remains of$
Al
Nagel
,�. g ' /• (State) (Zip -Code)'
(street) '(City)
who died on rl day of •
`'� •ab
(place) (Address)
~Name. and address oif nearest living relative or name of person
. ' authorizing crRplat i on t •
s - ?_ • w 0
Name) Address) �
" Relationship to the deceased • ^
" Name of Funeral Home
XMPURTANTA the deceased has or
';re resent that to the best of my knowledge,
I M
has no pacemaker in his or her body. (Clrpl'4 ■n.e) '
I"certii'y that I have the full power and authorixation to arrange
<: of
for`the crumation of the remains and to direct the .dispnsition er
'the`'crew�atsd remains. that any personal possessions have either
been removed or May by destroyed, and agree -' to protect, defend
'= And" save harmless Dine 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 as
directed, whether such claims or demands are -nr are n ot wholly
gro dle s, fills fraudulent.
(Witness) (Address)
Address)
? : `(Signature of Relative yr egal Rep- and
Signtd on this dates .
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,►y 7Yf .T ; .
it I SPUR I T I UN OF 4 cnEm my Ruin i NS
I hereby dlrect . Pina- View Crematorium to dispose of the cremated
remains as follows :
I %.I k
Mail to ,
T
i
Other drrangements` please specify :
,if pulvttrizatiun or cremate remains is requested, check here
PUS I C I ES, RULES AND IIEGULAT i QNS
1. The cremat or,ium * wi11, b.e open For cremat.lons• . 5 days. a week
7100 A. M. -- 3130 R. Ph Monday-Friday. • No Holidays or Sundays,
arrangements can be Made for Saturday. Prearrangements by
telephone For acceptance of remains is necessary:.
E. Pine - View Crematorium is located- on the grounds of the Pint;
View Cemetery, Cluaak er' Road, Town of UueensbWry.
3. An authorization for cremation properly . signe.d by the nearest
;next of Itin or other. authorized person sit.ating 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 liven 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 Elie 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
regains.
'k. All remains must be ariaised in a, casket nr suitable alternate
container. Caskets and containers must be of combustible
Material. No styraFeam or, plastic containers will be accepted.
`3. •. The question relative to cardiac pacemalters must be answered
on the authorization to cremate form before the remains will be
accepted.
6. Unles$ other arrangements are made the cremated remains will
be mailedvia Registered U. S. Mail within three days of cremation
to the funeral home handling the service. There will be a s20. 00
charge far this servi e.
Cremation, Administration Costs and Recording Fee: Adult $105. 00
Children (age 13 monl;hs to 12 years) t110. 00 Infants ( stillborn
to ' 12 months) f70. 00
Z0 39Vd NV-n3-10OW 0096b588I5 6b 80 Z00Z/60/60