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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