Wilson, Paul 70 UN of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
,
Funeral Director I�/ t oo-y - 1--�
Name Case#
Date Of Cremation (Q - 2G 0
Time Cremation Started
Time Cremation Completed 3 "� 1 ✓�
Type of Container
Remarks
3c�
TOWN OF UUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:
Paul S. Wilson Male
(Name) (Sam)
195 Bull Rock Road, Ticonderoga, New York 12883
(Street) (City) (State) ( Zip Code)
who died on 15th day of January M =3
at his residence, 195 Bull Rock Road, Ticonderoaa, New York
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
_Donna R. Wilson 195 Buii Rock Road Ticonderoaa, New York 12883
(Name) (Address)
I
Relationship to the deceased wife
I
Name of Funeral Home Wilcox & Regan Funeral Home
I P PORTANT s
I
I represent that to the best of my knowledge, the deceased has or
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 removet4 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 as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address
I
(Signature of Relative or Legal Rep. and Address)
Signed on this date : ?i`v ) '
///sjo3
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremd ed
remains as follows :
Mail to
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 1 , 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 Di ne
View Cemetery, Quaker Road, Town of Queensbury.
3 . An authorization for cremation properly signed by the near( --it
next of kin or other authorized person stating that they do Iie ,Ie
the power and authority to arrange for the cremation of the rema., is
and to direct the disposition of the cremated remains, that � iy
personal possessions have either been removed or may be destr� id
and agree to protect, defend and save harmless Pine �il 'w
Crematorium from any and all claims and demands for loss of damagE. ;
which may be made against them by reason of or connected with t?
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 styrafoam 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 wil.L be
accepted.
6 . Unless other arrangements are made the cremated remains will. be
mailed via Registered U.S . Mail within three days of crematioi.. to
the funeral home handling the service. There will be a $21 . 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adul!.: $195 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 )' .M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 .00 .