Stone, Elaine L( T-nrWN OF QUEEN, B U�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
Funeral Director I L1�-CjC) IA
aTe 1� S�CJ Case P q t
-a e O Cremation ZZ' - -zoC
:^--e Cremation Started
' iTe Cremation Completed
T ^e o f C o n t a i n e r ('wl��`-Y 1^O 3C T�1 �� �Z'�(� _� �} Al 3 U
KeT:arks
GCS P-u-) (_-o I-
R
!2� 5D
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows,
t,,1ail to
"Ither arrangements-please specify
It pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
' File crematorium will be open for cremations 5 days a week 7.00 A.M - 3.30 P M. Monday-
Friday No Hoiida� s or Sundays, arrangements can be made for Saturday. Prearrangements
by telephone for acceptance of remains is necessary.'
-' fine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
1 Own of OLjeensbury
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 cirect 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 V ew 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
Tema ns and /or eisposition of said remains as directed, whether such claims or demands are,
or are not wholly crounaless, 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 must be of combustible material. No Styrofoam or plastic containers will be
accepted
3 he q_restion relative to cardiac pacemakers must be answered on the authorization to
cremate torrn before the remains w.11 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 $20 00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $225,00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to '12 months) $75.00
Adaitional $50,00 charge for cremations done after 3 00 P.M. Monday through Friday
Cremarions done on Saturdays will be charged the additional $50.00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY �1 `
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 ana Regulations to cremate the remains of:
(NAME) — (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of
J 200�
at cL E�'15 �Gt//S /77J5 %%!�L 64�5 /UPcli vej&4L
(PLACE) (A RESS)
Name and address of nearest living relative or name of person authorizing cremation:
A % Lie P.4r/o le"x �,Z/ ��Gl/F�-iG1 / ,� i �o.6Q0,F6�
Relationsnip to deceased
Name of Funeral Home 726se"
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 disposiiion 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.
JC1 Aa�/) --'4 �'t�� p c P
(WITNESS) (ADDRESS) 06
'SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:_