Howe, B. Eunice ' roq+N OF QUEEN
,5BU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director .ga133/=R+ A0C-5I\ 1
Name U/UIC,'t PU Lo Case# 3 "z�
'date Of Cremation C)03
Time Cremation Started T1 1 0 /y-1
' ime Cremation Completed L02
��,pe of Container (2,VL-vr—e) 130v&i-Z,3
Remarks
wv;
- 3
i
i
i
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 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
the authorization to cremate form before the remains will be
acc opted.
6. Unless other arrangements are made the cremated remains will
l within
be maiheled -iria funeralRhometered handling.thelservice. three
Theredays
willobecremation
the $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 5:00 P.M.
Monday 'through Friday. Cremations done on Saturdays will be
charged -the additional $100.00 Any remains received after 3:30
k P.M. Mon-Fri or Saturday will be charged an additional $100.00.
k
TOWN OF QUEENSBURY
PINE VIEW CEMETERY 3 2
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its Rules and Regulations
Regulations to cremate the remains of:
(NAME) (SEX)
t ,
(STREET) (CITY) (STATE) (ZIP CODE) A�kl/a 1�3a
who died on v�� day of Ark 1tiS7' 20.03
at a; P1 /Ti y'P.✓' /L�S�va�, l70 t!'e-2 /7,V a1,:sn»
(PLACE) (ADDRESS) � ,mot•,'/�t,� 0
Name and address of nearest living relative or name of person authorizing cremation:
X O i Cv 6
Relationship to deceased
�j � � i�a.lr.`6J1.i13�:J
Name of Funeral Home G s —/O � 0// ! s /r. /9�/`�
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE) .Z
ff rto
I certify that I have the full power and authorization to arrange for the cremation of the remains and Ands
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 ,a
.6—rematorium 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 demand are or are not wholly groundless, false or fraudulent.
( NESS) (ADDRESS)
(SIGNATURE OF Rr=LATIVE OR LEGAL REP.AND ADDRESS) LJ
Signed on this date: L�2,? —-3'
4