Wilson, Calvin ro WN of QUEEN,,,5BUP.,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,M . a. c,,t- Q K
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ate Of Cremation G
Time Cremation Started fC� �- lo.
Time Cremation Completed � , 0 A/`,
Tvpe of Container Woo) Ova ysk5t ' , aa/v\
Remarks
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` TOWN OF QUEENSBUR,Y
j PINE VIEW CEMETERY
CREMATORIUM
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Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44"i6
1 AUTHORIZATION TO CREMATE
he and ersianed reqrium, in accordance with and subyect
uests and authorizes Pine View Cremato
o its Rules and Reguiations to cremate the remains a
Calvin C. Wilson (SEX)
2946
NAME)
( `
1 NY 1
1{ Hurley Ave. , Lake Placid, (STATE)
(Zip CODE)
(STREET)
(CITY)
day of
Jul 2Q03
Iwho died on 13 th
`gat Adrk Medical Center
Saranac Lake NY -----r
(PLACE) (ADDRESS)
Name iand address of nearest living relative or name of person authorizing
cremation'.
NY 12946
Hurle Ave. , Lake Placid
' Mrs ;Betty Wilson, 99
Wife
Relationship to deceased
M B Clark, Inc. , 27 Saranac Ave. , Lake Placid1296
Name,of 1=uneral Home
IMPdRTAhfT best of my knowledge, the deceased has or has no Pacemaker in his or her
I he
I represent that to t
body. (CIRCLE ONE)
for the cremation of the remains and.
personal possessions have either beej�: .
I certify that l have the full power and authorization to arrange
Ilto direct the disposition of the cremated remains. that any p es which may be made
remo':ved or may be destroyed, and agree��mands foreloss or damag harmless pine Viewether
Crematorium from any and all claims and of said remains
a airjst them by reason of or connected with i the cremation
se or fraudulent directed, w
g r are not wholly groundless,
such claims or demands are o
27 Saranac Ave. ,(ADD SS) Lake Placid NY 12946
E
(WITNE S) Lake Placid, NY
99 Hurley Ave. ,
(SI TURE OF RELATIVE OR LEGAL REP, AND ADDRESS)
July 14, 2003
Signed on this date:_
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DISPOSITION OF CREMATED REMAINS
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I hereby:direct Pine View Crematorium to dispose of the cremated remains as follows:
ail to _; M B Clark, Inc.
27 Saranac Ave. , Lake Placid, NY 12946
JCher arrangements-please specify:
if pulverization 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. - 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
{I person stating that they do have the power and authority to arrange for the cremation of the
iremains and to direct the disposition of the cremated remains, that any personal possessions
haveeither 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 remains must be encased in a casket or suitable alternate container. Caskets and
,. 4p 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.
I ' g + r f C r d a egi
� 6.I ,Jnless other arrangements are made fh.: cremated remains will be rnaile.. 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 lematim Administration Costs and Recording Fee: Adult $300.00 Children (age 13 months to
1 yyears)'$150,00 Infants (stillborn to 12 months) $100.00
dditioral $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cii ematio6s done on Saturdays will be charged the additional $50.00.
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