McCartney,Helen """"'74N OF QUEEVBU-I �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A�. �
Name OACC,P kT N r,�A Case#
Date Of Cremation 01--12
Time Cremation Started D
Time Cremation Completed l' t o e �-
Type of Container 5[1�jt!G- ( y,g)Lq c otj-D a3.,,► zd r Ls rim
Remarks
22 CA-2 c2tic)— I i
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TOWN OF QUEENSBURY �
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 remaina• of:
Helen M. McCartney Female
(Name) (Sex)
4820 State Rt. 8, Riparius, New York 12862
(Street ) (City) (State ) ( Zip Code )
w h o d i e d on the 'Irrl d a y of January 3a 2003
at Adirondack Tri—County Health Care Facility, Johnsburg, New York 12843
(Place) (Address)
Name and address of nearest living relative or name of pe� scn
authorizing cremation :
Mary Ellen Jackowski, 4820 State Rt. 8. Riparius, New York 12862
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander Funeral Home, Inc. , North River, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased M
has no pacemaker in 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 or
the cremated remains, that any personal possessions have either
been rexoved or may be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against then* by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wnoliy
grounc;.l)ess, false or fraudulent .
Alexander, 3809 in St. , Warrensburg, NY 12885
(Witness ) (Address)
J+ - . q (2,X-:e J Mary Ellen Jackowski, 4820 state Rt 8)PO Box 25
(Signature of Relative o Legal Rep. and Address) Riparius, NY 128e2
Signed on this date :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the emate remains as follows :
Mail to
Other arrangements — please specify :
If pulverization of cremate remains is requested, check here
POLIC
IES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations S days a wee
7 :00 A.M. — 3: 30 P. M. Monday—Friday.
iday. No arrangements can be made for Saturday. Holidays earrangementsa s ,
telephone for acceptance of remains is necessary, y
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 next of kin or other authorized person st nearest
the ating that they do tim e
power and authority to arrange for the cremation Of t ^ e
remains and to direct the disposition of the cremated remains ,
that any personal possessions have either been removed or may Le
destroyed and agree to protect , defend and save harmless pt . e
View Crematorium from any and all claims and demands for loss o =
damages which may be made against them by reason of or connecter
with the cremation of said remains and/or disposition of sa : z:
remains as directed, whether such claims or demands are, Or are
not wholly groundless, false or fraudulent ,
in addition to a regular burial permit remains. mustisaccompanyat ` `
4, All remains must be encased in a casket
container. or suitable alternafe
Caskets and containers must be
material . No styrafoam or of combusticle
plastic 5• The question relative to cardiac containers will be accepted.
on the authorization to Pacemakers must be answe�-e�
accepted. to
form before the remains w111 re
�• Unless other arrangements are made the
oe mailed via Registered U. S,
to the Mail within threemdays of
funeral h Cremat :
home handling the service. There will be a
=harge for this service.
�:remation, Administration Costs and RecordingFee : A
-hlldren (age 13 months to 12 Adult s �5
10 12 months ) s60. 00 Years) t100. 00 Infants