McHenry, Dorthy . rrnTVN OF QUEEN,5BU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i Funeral Director 4t ,` a
Name -��ly LC �2h�`�Case # s og
Date of Cremation
Time Cremation Started � .
Time Cremation Completed < LIS
Type of Container c� hr,arCX
Remarks :
J, F'2s+ C,4 C'e o� ar�i 3S Yar'►'�
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify:1�iL� f'ic/( Lip
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
Towncated on the of Qu ensbury grounds of the Pine
View Cemetery, Quaker
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 o fraudulent.
accompanyatheorizatio remainsn in
addition to a regular burial 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 to crematediac pacemers form before the must
rema ins will rbe
ed
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered
S. Mail
servicen three
Theredays
willobecae$25100
to the funeral home handling the
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 one on Saturdays
ys will
be
charged the additional $100.00 Any
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 745-4476
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:
(NAME) t (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on y day of A/ U 20 o Z
at (oLl�f'S ACC S S.DiT�� L/ S �i9S �Y/�
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased —��/G� / ��
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as 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
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 dema ds are or are not wholly groundless, false or fraudulent.
L
(VVtYWW (ADDRESS)
it /y
(SIGNATURE OF RMATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: /122J 2