Toohey, Thomas OF QUEEVBUPJ,-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 5- �r4 F- c-
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Date Uf Cremation 9 — , ? _ _Zoc'
=me Cremation Started 7l
dime Cremation Completed C7
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Remarks
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DISPOSITION OF CREMATED PRO-INS
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 ip 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-Fri or Saturday will be charged an additional $100.00.
TOWN OF QUEENSSURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
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:
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(SE) AK I , . (SEX)
(STREET) (CITY) (S TE) (ZIP CODE)
who died on day of 20 73_
at W C S'
(PLACE) (AD RESS)
Name and address of nearest riving relative or name of person authorizing cremation:
Cx�xkiA -1—aofk6j:� I 1,<SA �i&" Raiu-r BLUR, a cF4-,FL.oR�9A
3343,'r
Relationship to deceased JMo-T*6P-
Name of Funeral Home 'TNrFFoRO c.tiE L F, Nc, nF LAKE, l�oe0e
IMPORTANT
1 represent that to the best of my knowledge,the deceased has or 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
L`rematorium from any and all claims and demands for loss or damages which may be made
;against them b reason of or connected with the cremation of said remains as directed,whether
such errands are re of wholly groundless,false or fraudulent
�� ALUA4a aw f",OPP
TNESS) ( RESS) 33113S'
C. Lo�t�A
(SIGNATURE OF RELA E OR LEGAL REP.AND ADDRESS)r 339/3.S'
Signed on this date: