Page, Jane ' ro rMN OF QUEEN
,5B UP_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /i ! �� �, J,,�1Z, K
Name �-�l�f N"F w PIA (;16 Case#
Date Of Cremation - 13 - ZG4
Time Cremation Started
Time Cremation Completed
Type of Container C,,y,NXC)' %\j ' �'� �J\1
Remarks \
l 4.
V2 o 0
t 110
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DISPOSITION OF CREMATED REMAINS
I I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
lail to
therarrang-ements-please specify, To be called for 05/13/03
I Ipulwerization of cremated remains is requested, check here XX
POLICIES, RULES AND REGULATIONS
1 The 'Crematorium will be open for cremations 5 days a week 7:00 A.M. - 130 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
i� person n 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 or 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 reirnains 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
11 accepted.
511 The luestion relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
B.I. Unlegs 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.
C ematior'!I, Administration Costs and Recording Fee: Adult$300-00 Children (age 13 months to
1, years)'$150.00 Infants (stillborn to 12 months) $100.00
dclitioria! $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
the additional $50,00.
C�e� rnatioli s done on Saturdays will be charged
TOWN OF QUEENSSUR.Y
i PINE VIEW CEMETERY
i
CREMATORIUM
Quaker Road, Queensbury, New York 12894
Phone (518) Crematorium 745-4477 (if no answer}
Cemetery 745-4476
I AUTHORIZATION TO CREMATE
um in accordance with and subject
he undersigned
requests and authorizes Pine View Crematori
o its Rules and Regulations to cremate the remains of
Female
Jane W. Page (SEX)
(NAME)
4Jest Heights #3 Lake Placid, NY 12946
(STREET}
(CITY} (STATE) (ZIP CODE)
iwhd died on
202003
12th day of May
Residence ----�
i (ADDRESS)
(PLACE)
Name land address of nearest living relative or name of person authorizing cremation:
Howard E. Page 2656 No. 56th St. , Mesa, Az. 85215
Hixsband
Relationship to deceased
ameofFimeralHome M B Clark, Inc. 27 Saranac Ave. Lake Placid, NY
N 12946
�jIMPORTANT
� 1 knowledge, the deceased has or has no pacemaker in his or her
represent that to the best of my
I� body.' (CIRCLE ONE)
I certify that I have the full power and authorization to arrange
for a crerna ion of have either been
the remains and
to direct the disposition of the cremated remains. that any personal possessions
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 claims or demands are or are not wholly groundless, false or fraudulent.
27 Saranac Ave. , Lake Placid, NY 12946
Y(WINESS) (ADDRESS) 2656 No. 56th St.
Mesa, Az.
85215
(SIGNATU E OF RELATIVE OR LEGAL R AND ADDRESS)
05/12/03
Signed on this date:-