Coolidge, Everett rro(14N o f ' QUEEVB U-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l U �--
Name Eye'a-: Tr cdnL11)6'1� Case#
Date Of Cremation 1 -2— 3 ( — 2V02
Time Cremation Started 9 S 0 �Atil
Time Cremation Completed
Type of Container pirr\2-dk9adD 0(u'o1<cA' M 0,
Remarks
CA-0 'Z C'A4 e- r��� 1 o a5
UCH M i
1
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify:
.mil ,c
If pulverization of cremate remains is equested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations Holidays5days or week
7:00
A.M. - 3:30 P.M. Monday-Friday. pre-arrangements by
arrangements can be made for Saturday.
telephone for acceptance of remains is necessary.
2. Pine View Crematoria Town located Queensthe grounds of the Pine
View Cemetery, Quaker Road,
the
3. An authorization for cremation person stating tharoperly signed t they doahave
rest
next of kin or other authorized p
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 Styrofoa or plastic containers will be accepted.
m
ers
must
5. The question relative r mate cardiac form bpacemefore the rema ins will answered
be �
on the authorization to c
accepted. �
ins will
6. Unless other arrangements are made the cremated of cremation
be mailed via Registered U.S. Mail within three i
to the funeral home handling the service. There will be a $25.00
charge for this service.
Cremation, Administration
to°12s ear s) $15 Recording 0 FeInfantst (stillborn
Children (age 13 months Y
to 12 months) $100.00
* Additional $100.00 charge for cremations done after 3:00 P.M.
ions done on Saturdays will be
Monday through Friday. Cremat
$100.00 Any
remains received after 3:30
charged the additional will
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
I
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:
(NAME) t t (SEX)
6117
(STREET) (CITY) (STATE) (ZIP CODE)
who died on c2 `' day of 20Aa
at � U�-�L �T�� �" /,,CC" S4
(PLACE) (ADDRESS)
Name and address of nearest living relative or name'am }of person authorizing cremation:
ann
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased ae as no acemaker in his or her
body. (CIRCLE ONE)
I certify that 1 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 laims or demands are or are not wholly groundless,false or fraudulent.
(WITNESS (ADDRESS)
//
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7` t)J
( NATURE OF E"L"ATIVE OR L AL REP.AND ADDRESS) .
Signed on this date: 22z& -1 o�y��200o2