McWaters, Olive TOWN OF QUEEVBUr�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -)�U 13 j- `4
Name � �' 1� � M � i��'S Case# 1,
Date Of Cremation — 1_j- -Z-(-)o 3
Time Cremation Started ( -2, -0 \0 /"
Time Cremation Completed l 3 /l/�
Type of Container 0\0'-\')-o �3dr40-d pit-
Remarks
62,1
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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) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on atk
�f day of n CAC' N 20_03
(PLACE) (ADDRESS)
Name and address of nearest living/relative or name of person authorizing cremation:
'r'air G✓ rs
Relationship to deceased J04
Name of Funeral
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has 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
succlaims or nds are or are not wholly groundless, false or fraudulent.
(WI SS) (ADD SS)
T/
(SIG RE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: Df --/a -03
DISPOSITION OF CREMATED RAINS
ereb direct Pine View Crematorium to dispose of the cremated
I h Y
remains as follows:
Mail to All
Other arrangements - please specify: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
3.30 P.M. Monday Friday. No Holidays or Sundays,
A.M. - Pre-arrangements by
arrangem
telephoneenfor acceptancets can be s of remains tis necessary.*
telephone
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
ro
3. An authorization for cremation properly signed by the nearest
that they do have
next of kin or other authorized person stating of
the power and authority to arrange f of the crematedematio or n remainsn
the cr
remains and to direct the disposition
be
that any personal possessions have either
defendand save harmless Pines View
destroyed and agree to protect,
Crematorium from any and all claims and demands for loss of
damages which may
be made against them by reason of or connected
aid
with the cremation of said remains cla claims demands are, or care
remains as directed, whether s
not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany
thealternate
4. All remains must be encased s ket must orbeU1ofblcombustible
container. Caskets and containers
material. No Styrofoam or plastic containers will be accepted.
5. The question relative to cardiac
before the ers must
rema ins will answered
be
on the authorization to cremate
accepted.
ated remains will
6. Unless other arrangeme
be mailed via Registered U.S.s Ma 1 withinre made three mdays of cremation
to the funeral home handling the service. There will be a $25.00
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 done on Saturdays will be
charged the additional $100. 00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.