Hayes, James 7o(v4N OF QUEEVBUP.,.y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (M
Name + �1'l.�s �`� S Case# s
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container C h , Y1,2,-N , Yzd -(yevtJ
Remarks
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DISPOSITION OF CREMATED REMAINS
to dispose of the cremated remains as follows:
I hereby direct Pine View Crematorium
r
Mail to
Other arrangements-please specify!
If pulverization of cremated remains is requested. check here
POLICIES, RULES AND REGULATIONS
P.M. Monday-
1. The crematorium will be open f for cremations ements can be made os a week 0r Saturday.OPrearrangements
Friday. No Holidays or Sundays, 9
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.
orized
3. An authorization for cremation a theerlypower and authority to arrange for the cremagned by the nearest next of kin or other tion ofthe
person stating that they do have p
remains and to direct the disposition of the cremated remains, that any personal possessions
or may be destroyed and agree to protect, defend and save
have either been Bator um from any and all claims and demands for loss or damages
Crematorium
on
which may be made of said remains as directed, whether against them by reason of or connected irs such the ccla msl or demands are,
of said
remains and for disposition
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
m ter al.suitable
Styroalternate
or plas tic conta nerstwal be
container
s must be of combustible
accepted. �
tive to cardiac pacemakers must be answered on the authorization to
5. The question rela
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
9
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 forcremations il bcha god the addition.$50.00 ay through Friday.
Cremations done on Saturday
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:
JAMES T. HAYES SR. MALE
(NAME) (SEX)
103 MCCREA STREET, FORT EDWARD, NY 12828
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 28TH day of DECEMBER 2002
at HOOSICK FALLS HEALTH CENTER, HOOSICK FALLS, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
JAMES HAYES, 78 GRANT AVENUE, GLENS FALLS, NY
Relationship to deceased SON
Name of Funeral Home M. B. KI LMER FUNERAL HOME, 82 BROADWAY FORT EDWARD, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no acemaker 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
Crematonu from any and all claims and demands for loss or damages which may,be made
against the b e n of Or on ected with the cremation of said remains as directed, whether
such clai d ar a not wholly groundless, false or fraudulent.
(WITNE.' (A R
(SIGNATURE O RELATI E OR GAL REP. AN DRESS)
r.
Signed on this date.