Welmaker, Mary OF QUEEN,,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-z�o 1�) K �� J
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Date Of Cremation 3 — Z — -z-0
Time Cremation Started
Time Cremation Completed ` 1 D
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Remarks
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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:
MARY ELLEN WELMAKER FEMALE
(NAME) (SEX)
1098 NORTHCREEK ROAD, PORTER CORNERS, NY 12859
(STREET) (CITY) (STATE) (ZIP CODE)
who died on
9TH day of MARCH 2003
at SARATOGA HOSPITAL, SARATOGA SPRINGS
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
WILLIAM WELMAKER, 1098 NORTH CREEK RD, PORTER CORNERS, NY
Relationship to deceased FATHER
Name of Funeral Home WILLIAM J. BURKE & SONS FUNERAL HOME
IMPORTANT
I represent that to the best of my knowledge, the deceased_tM.Vr has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that 1 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 Yew
.Crematorium from any and all claims and demands for loss or damages which may be made
:against them b demands arer connected with or are not wholly groundless,dnation of said remains less,false or fraudulent.
directed,whether
such Maims or
r-
fJ 7,� �C—e—e—t 628 N. BROADWAY, SARATOGA SPRINGS, NY 1286
TNESS) (ADDRESS) AJ
OIGNA R OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: 3/11/0 3
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: BURKE FH WILL PICK 11P
If pulverization of cremate remains is requested, check hereXX
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 is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
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
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 Styrofoam 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 will be
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U.S. Mail within three days 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-r'ri or Saturday will be charged an additional $100.00.