Loading...
Ross, Beatrice r"O rWN OF QUEEN,50U KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director a IJ15c) 1 \4 n a-e Per/� � LC Case# ate Of Cremation ,� 2 3 20G� 7e Cremation Started /A/l . --e Cremation Completed ?�Q3S A/"-k � . oe of Container �,L� �y4 r A44 1 Ad- i DISPOSITION OF CREMATED REMAINS I hereby direct Pule View Crematorium to dispose of the cremated remains as follows. ",lai1 to Other arrangements-please specify. Ir pulverzation of cremated remains is requested, check here POLICIES, RULES AND REGULATIONS Fhe crematorium will be open for cremations 5 days a week 7 00 A.M. - 3:30 P.M. Monday- Friday No Holida�,,s or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance of remains is necessary.. -' Pine View Cr_ ematcriurn is located on the grounds of the Pine View Cemetery, Quaker Road, own of Queensbury An authonzauon 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 cirect the disposition of the cremated remains, that any personal possessions I'ave 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 rema ns 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 curial permit must accompany the remains. 4 All remains must be encased in a casket or suitable alternate container. Caskets and containers nnrst be of combustible material. No Styrofoam or plastic containers will be accepted The q_,estion relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. �. 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 $20.00 charge for this service. Cremation, Admrnis;ration Costs and Recording Fee: Adult $225.00 Children (age '13 months to 12 years) $115.00 Infants (stillborn to 12 months) $75.00 Additional $50,00 charge for cremations done after 3.00 P.M. Monday through Friday Cremations done on Saturdays will be charged the additional $50.00. TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM . 5� 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 ana Regulations to cremate the remains of: Ag (NAME) (SEX) /r. t�g�2 �j�j2,v��� am l/1 /U / (STREET) (CITY) (STATE) (ZIP CODE) who died on / 7 day of © e 7— 20 a3 at 6-461-7-s ��3��S 1A S _ i%C- (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Sc b LA.). W4'7,acl N . 1�14&7 Relationsnip to deceased v.� Name of Funeral Home_ IMPORTANT I 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 disposinon 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 as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. (WITNESS) (ADDRESS) ;SIGNAT�REF RELATIVE OR LEGAL REP. AND ADD ESSt i (P Signed on this date: 3