Loading...
Johnson, William rl-o q+N OF QUEENs5BU,� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 13c0z Kr-� Name W 1VI — 1 /dam Case # Date of Cremation Time Cremation Started /-lk Time Cremation Comoieted ® ,-o Type of Container -f3a ) 1� Remarks : f G' `�5�v-)---Zr DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Cr'ematorlUnl to dispose of the cremated remains as follows. Mail to Other arrangements-please specify If pulverization of cremated 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. Prearrangements 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 or 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 relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6. Unless other arrangements are made the cremated remains will be mailed via Registered U.S. Mail within three days of cremation to the funeral home handling the service. There will be a $20,00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $225.00 Children (age 13 months to 12 years) $115.00 infants (stillborn to 12 months) $75.00 " Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50.00. Nov 14 02 12: 28p Newman Seafood 252 926 1642 p• 3 11/1?/2©72 14;29 518-F84-0147 WM. J. BURKE L7tdS ?,6G_ 04 TOVA Or O'JEENSBUFY 't PINE VIEWCEMETERY CREMATOR1lJt! Quaker R oaq, Oueenab,,:'y. Neer York'12.50,4 f Phone(519)Crematorium 745.4477(if no answer,, ! CSMetery 745-4476 AUM2CRIZATION TD CREMA'E The ur.der;ig etl recuescs and authorzes Pine View Crenmorurn, r. acccrdance wilt•and suu;ect to t!s PueS a .a Reguiatioru to cremate the remains of: MILLI M ALBERT JOHNSON MALE (N'Af E) :SEX) l-/. S,4z,*, l SiGuAgs AIV �.?84 F -5�2z/ (STR ET). CITY) (STA-E) Z.= CODE) Nrc ti eti cr. >.2 Cie y of t10Vrw.5eW 2n oZ at r 4.4 0VW ro[_ o (PLATE) i;AD0REti:ij V,.`Tt Name and ad rase of re lb uif,* tbr�atcnnme fir,' utbrx+zyragrrematior. —er•nece-%, 71.5-4476; MR-1 ir?,IIWsi; 3w,�,JQuA,t;Fi2i .�r'c ��fisa; Zel3ticnsNn; deceased J01%/ "^e Jr�ersi. ec um., ac;vrcance :t> , t0 It5 a C R"QL'3t"n r0 "N ,pie t T9 er `i ,4 19 0 . a. vrrFe o!Fin el @I:-i4me l�i�v���J. 4,.Kxf ' S�;ts Frt U&.4e r eE M AL EFT Jf:HN771 fAA?CraTTag4T .j ,.: .. !iep�e:a i�±tha tb tht-bast of my kndWledge, the deceased' o pac>�ma'te ir,nIs or rar ' bao�r ',CIR�L ONE; the full pou*F'and author mon to s�{y 1~; fgjy cremation of the rernsq*,#Ld to direr t tha al o i�"e`TTri rema'T�Fafians. that H?Py poTsonaT possession removed o-me be deatroyed,and agree to protect, defend and sa}o harmless Pine Vlea ; ematari r ,�rd ;r j; wand oemands for roes or damages which may be made aCain; , EBa.9 n n ar rani a crcnfl'3ii? �fi'is�i� omati such !alms errands are are not wh0li;r groundless,to se or fraudulart I/ OD- ., rS3 A!Y (WT-N SS; jV ADDRESS) n.O ./ Iy . t fo.r se f! �/!'C. /Y1A�,✓ si._ SC .?r✓ l�t1A.4,'t72 Ale— �7r•,+'� "ems►''`_ &0 /h/j✓w S% jai&& 444AM&WIC •9'7Hr5� SiGVA JRE P RELATIVF OR LEGAL REP.AND ADDRESS; �=.er'a:i�r_==,71: di?cedSE7 for✓ S,red on this d CW ',7-re o' F.sn-,. ! mt W�v r •�. 12 ` (� K Jl::1S F�CNCI�JjL / -J f,'r.E ti C�rtlry :Itc:; n Ve the ful'. Power and a.,thori.aCOn'o wrarige for:hs'=rer:na.,.^,n of tie re'-.1;r•s and ttr at'aiv perso^1af DGsGessr011s havr- :1el, dean ram0'�Fd C'rne. be V eV, and agree to RretGL,, ?�fesd and save t1airr:IIE:57 Fine\;',ENV vFeiTiatCr:ra Tl}" ir any an❑ail clexns a"d cerna^ds fcr I3e6 o'Cail2reS 1:'i1iCh r1ey Yht�n,ads �C3 n,t ii I C' rea.9 1n of nr Canrf;cted urith tr:s c-iamakrI of+u--i0 rt,-MO ,S as dlrecte", 'vti'r1c'.�t�r SUCK C;2!M,' p' ema- + s are�,-3.c n3: vrhCliv GrcU"d1esS, t95e 7,�'r3ur4zr!