Brocca, Grace rl-o WN OF QUEEM
,s5B UJKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director EL-\-r-l�ti--p��— �
Case #
Date of Cremation 2 S� - -z--
Time Cremation Started n 1-� �� v�-
12
Time Cremation Comoleted
Type of Container
Remarks :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: Will Pick up
If pulverization of cremate remains is requested, check hereXX
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open forcremations Holidays5days or week
7:00
A.M. - 3:30 P.M. Monday .F yPre-arrangements by
arrangements can be made for Saturday.telephone for acceptance of remains is neecc
essary.*
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
orized person stating that they do have
next of kin or other auththe
the power and authority to g on f or of t e crematedn remains,
remains and to direct the dis possved or
that any personal possessions hdefendve either
and save harmless Pine a may
destroyed and agree to protect,
Crematorium from any and all claims and demands for loss o
damages which may
be made against them by reason of or connected
with id
the cremation of said remains and/or disposition of
nds are, r sere
remains as directed, whether
eth erorufraudulent.ch claims or Thisaauthorization in
not wholly groundless, the remains.
addition to a regular burial permit must accompany
stae alternate
4. All remains must be encacontainers as must orbeulofblcombustible
container. Caskets and
material. No Styrofoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers rm e mremains will answered
on the authorization to cremate
accepted.
ated
ins will
6. Unless other arrangements a within threemdays of cremation
be mailed via Registered U.S. Mail
to the funeral home handling the service. There will be a $25.00
charge for this service.
nd Recording Fee: Adult $300.00
Cremation, Administration Costs a
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.
Cremations done on Saturdays will be
Monday through Friday.
A
charged the additional $100.00 Any remains received after 3:30 P.M. Mon-Fri or Saturday will be charged an additional $100.00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8�
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:
Grace E. Brocca Female
(NAME) -- --- - t (SEX)
20 Woodlawn Ave. Greenwich, NY 12834
(STREET) (CITY) (STATE) (ZIP CODE)
23rd September
who died on day of 2002
at McClellan Health Systems Hospital Cambridge, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Linda Bergquist, 212 County rt 52, Greenwich, NY 12834
Relationship to deceased Daughter
Name of Funeral Home Flynn Bros. , Inc.
IMPORTANT
I represent that to the best of my knowledge,the deceased has or 9bacemaker in his or her
body. (CIRCLE ONE)
1 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 r on of or connecto with the cremation of said remains as directed,whether
s c i s or ads €OT ar wholly groundless, false or fraudulent.
Flynn Bros. Inc. , 80 MainsSt
Greenwich NY 12834
TN SS) (ADDRESS)
212 County Rt 52 Greenwich NY 12834
(SIGNATURE OF RE OR LEGAL REP.AND ADDRESS)
9-24-02
Signed on this date: