Kelley, Jane 7O`MN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 13 U 1z� K.
Name XA K`F, Al �,f LLF-�t Case#
Date Of Cremation - a, - -2L0o
Time Cremation Started I p N\.
Time Cremation Completed t 0" � y N\
i
Type of Container�'i�4\Z-0 A-30►4L7—J (fptA-\- �0.2,sA�
Remarks
G�vawF�� 2 Lws C d1�,��I��If,VI to Lls
l� fo
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows.
Mail to
Other arrangements-please specify: 1'3(4'0k£15 u 1'lt"
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 ;: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 ar,ange 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
OWN OF OUEENSBURY
PINE VIEW CE'fiETERY
CREMATORIUM
Quaker Road, Queensburv, 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) (SEX)
P0jvFC-AZ, c,,wA�/� SA i , N
(STREET) (CITY) (STATE) (ZIP CODE\
who died on day of _ �� _200 7—
a t �� 00 Al t--e-4 L 1,.14 y -
(PLACE) (A DRESS)
Name and address of nearest living relative or name of person authorizing cremation:
_-,� ��
/V
Relationship to deceased
Name of Funeral Home ✓�'1 LJ� �� Jl/J�"
IMPORTANT
I represent that to the best of my knowledge, the deceased has o .,as no acemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for t E cremation of the remains and
to direct the disposition of the cremated remains, that any person; I E ossessions have either been
removed or may be destroyed, and agree to protect, defend and E 3ve harmless Pine View
Crematorium from any and all claims and demands for loss or iar ges which may be made
against them by reason of or connected with the cremation o saic remains as directed, whether
such giainiwor de ands are or are not wholly groundless, fz se o, fraudulent.
�1g NI ��a✓,4y
(WITN S) (ADDRESS)
k24�1 lldl& // L--44 L/
(SIGNATURE OFF RELA E OR LEGAL REP. f ND ADDRESS)
Signed on this date 2-02—