Nelson, Stella rroW N OF QUEEM 5BU.�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director )3 )1,, d,S
Name 5+F�� Case # q0 "I
Date of Cremation
Time Cremation Started b V/V%
Time Cremation Comoleted
Type of Container (���PC<C.� 'Q��2�, Iv ' c—I%1:�--
Remarks :
s� �-ILI
i
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: W1 ick up
If pulverization of cremate remains is requested, check here X
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 on ato cremate form befor the remains will
cardiac to e m banswered
on
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via RegisteredU.S. Mail
within
hree dioce1
on
to the funeral hom andlingtheservice Therewllbea $2500
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 nreceivedSaturdays
will
er be
charged the additional $100. 00 Any remains
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
yo �.
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:
Stella E. Nelson Female
(NAME) it (SEX)
Plesant Valley Nursing Facility 4573 State Rt 40 Argyle, NY 12809
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 22nd day of September 20 02
at Pleasant Valley Nursing Facility Argyle, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Sandra Bess 605 East 39th St. -Farmington, NM 87401
Relationship to deceased Daughter
Name of Funeral Home Flynn Bros. , Inc. - Greenwich, NY
IMPORTANT
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
.L ematorium from any and all claims and demands for loss or damages which may be made
a inst them by r on of or connected withJhe cremation of said remains as directed,whether
such laims, d�s e w If roundless,false or fraudulent.
80 Main Street Greenwich, NY 12834
( TNESS) ESS)
605 East 39th St. Farmington, NM 87401
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: Sept. 23, 2002