Steves, Norman TO(TIN OF QUEE9Q50U-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
Case;. §71
Cremation
Cremation Started
I
' : T.e Cremation Completed
" oe of Container �-C)
gr
-arks
I
i
i
i
AA sr
40
- FIBS
Body Delivery Receivt
(Required by Section 414 5 - NYS Public Health Law)
A. NAME OF DECEASED PERSON: A6Kr),nij
(as it appears on burial,cremation or transit permit)
Z// /�)d a
B. DATE THAT BODY WAS DELIVERED: ,>(
C. NAME AND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAKING DELIVERY-
J0,C f
L2 *i
(Print Name) (Reg. #)
D. NAME-,OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral Firm Name)
E. NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSMON WHO RECEIVED THE BODY:
(Print Name)
CHECK IF NO ONE IN CHARGE
F. NAMEACICATION OF PLACE OF FINAL DISPOSMON.-
C.
L
(Name) i (Ci ,State)
(SIONATM of Fu*r9f Director) (SIGNA
of Person Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Blue Copy-Decedent's Family
si
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: �� W
If pulverization of cremated 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 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
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 i emains 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$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.
I
I
3
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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 to cremate the remains of:
!1/4RYI14A.) H4&'E
(NAME) (SEX)
N L y (�U CA& ..4e 11 011 1,2
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 6 e d 3 day of 20
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home WAD j,��F ��I J l'Ur t -
IMPORTANT
I represent that to the best of my knowledge, the deceased has cllr has no emaker 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
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason f or connected with the cremation of said remains as directed, whether
such claims o dem d are7orre not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATUR OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: d