Wheeler, Charles TO(KN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director )3u)Z y i F —
NameOLR)'EL' W eck-g j-)� Case#
Date Of Cremation
Time Cremation Started �� � Jr 1�
Time Cremation Completed - J (� v'�`` 1✓�
Type of ContainerG� F3C1r/�l
Remarks
TOWN OF QUEENSBURY
} PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(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:
Char 1 ac yyh , or Ma a
(NAME) (SEX)
270 P rami8 Pi ncc Wgl-.Foo SS . UV„ 19RAF,
(STREET) - (CITY ) (STATE) (ZIP CODE)
who died on 25 day of H a h r 1,a r cr 20. 03
at -
(PLAC )
Name and address of nearest living relative or name of person authorizing cremation:
i�co yram bly 12866
M r G R a r li a r� S,t �,6� 27n P
� i G�{ $��2 S $r 6 6�r�� cG-^---^r r
Relationship to deceased --
Name of Funeral Home -
IMPORTANT
I represent that to the best of my knowledge, the deceased has o 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
.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 claimsor4emands are or are not wholly groundless,false or fraudulent.
(WITNESS) ( DDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date:c4�0-'u (�
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
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 7:00
A.M. - 3:30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.
2. Pine View Crematorium s located on
Queensthe grounds of the Pine
View Cemetery, Quaker Road,
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 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
Crematorium from any and all claims and demands for loss of
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
t. This
not wholly groundless,aregular burial permit must naccompany athe o rization in
remains.
addition to a regular
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.
diac
ers
5. The questiontive to
cremater form before the must remains will answered
be
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed funeral me handling the service. There will be a $25.00
Registered
three days oCe
mation
to the fumee
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 or Saturda will be charged an additional) $100 00.
P.M. Mon-Fri or Saturday