Mortensen, Ruth TO`WN OF QUEEN,5BUP�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4477
Funeral Director /t/l 13 C. t '►4 \�
T.e Case# 1-2- 5
gate 01 Cremation
Cremation Started :2
' i -, e Cremation Completed d
oe of Container 014-v>o S eg<;!l') AsN)
Kc^?arkS
i
)ISPOSITION OF CREMATED R,EMAINC
1bv',.CjjreCj� pine view Crematorium to dispose
ail of the UeMiMed rc�,j ins, as f If WS,
UP—
M B Clark, Inc-
27 Saranac Ave. , Lake Placid, NY 12946
Ie, specify II-ier-arj-,,aj)gefTjerItSPiP-aSh
s requested, check hem I �puiveritaboll of crernated rr mains
POLICIES, fjjjj_ES AND P .-GULAT ION 7
Monday-
11,
1,30 R M.
ions 5 dayS a Wept< U0 A,M. -
lie crernatol'lUrn Will be open for crernat -�,r �jaturday. Pre-al"Tangerne.11ts
f
T rangements can be Mad
prld�yl No Holidays Or Sundays, '3r
by te'lephono,for acceptance of M(MrIns is ne(,essary F)trle Vi(,,.w C -ery, Quaker Road,
t
'ated on tj)cj grounds vJ the
Pine,\/iew CreI"'8Wf4Jr` iS
,"own of Queensbury
x f kin Or ottler authodzed
�)cjned hynearesl next a
lifiorftation for cremation properly the cremation of the
3 Anao
pt�,rs(�n slating (j*Iat they do) havO, the ijt iority t(-)f3rra ige for
, pc)wex and Ternains, that Any personal ssions
(j to dirpot thF,% dispositIO11 of illp cremated e
I all �jo_, C)yF.,-j and agree to I)r0tci, defend andsave
'rna!Ilis oved or rn4y b(I _sjl or damages
h; ve�.elther been rern -n any and ail clairns and dc-!rnands for loss
harrNiess Pine View Crematorium fT01
v by Mason of(),oonnected with the (,je(rtafion of t aid
whic.,,6 may be Made against them aitIs as direc.-,ted, whether sur;h (,lairils or dernands are,
re�jyja,Ins and /r.)r dispositi0i" Of sai(J f-em nt, 1"�jis aut1jorizaflon in addition to a regular
r6 not wholly groundifi-ss, false (.,,r fraudUle
't @(X-,0TT1PaI_)Y the rernams
a(I)pr
r�""Cal rT0.mus
sod in a casKet or sklit2NO ts and
4. All rol'rnains mUst be el"C" husilible fnAteriM. WD Styrofo-an)o" c;ontainers will be
(�ontd.,iners j,tjust be of c;OM
acrepied
3} The r oestion relative to (`,Rrdi8c p8cBMakprs, Must be 2nswere(i oil the authorization to
b(. -I-)ains will be -X"epled
'� _forrn, W
-
lh t)p, miled via
6.1 UnleAi iy,)Me iiaw1il the the sere icRegiste re
e, Thered will
tj S. (.Mail within!thin tj,jree day�3 of crematiar) to the fLlrlel'al
be a 1525.00 charge for this Berviu.
osis and J'�etmid0iq Fee: Adult$300 00 Children (age 13 months to
J:";years):$15().00 Infants (stillborn to 12 manihs) $100 00 F Ida
fear (101-je rafter 3-00 P 1'0. Mondly through -r y
..dditiohal SWoo charge _q vvill tie charged t!le addiflC)MR1 $50,
C atiol's done an Gaturdav
"�DWN Ol' OIJE'FN'SBURY
PINE VIEW CEMETERY
(;REMATOR-iUM
Qtaker Road, (),_,eensbury, 1,4ew '� ,ork
r),)One (5 18) C .1torijinj '7454477 (if 110 answer?
AUTW)RIZATION 10 cf�J-.MA'ri-;
d authorizes Pine View CI.E"nat0flt-1m ir, accordance with and subject
Is undersWned requests an rernams of"
andRPqWafl0nS toc -1 r the
OIL
(SEX)
i,(NAME)
e.30 Greenwood Street, Lake Placid, NY 2
(,,,:T�'-- '_'�T'; CODE)
TE)
(ciTy)
(STP
March. 4
12th day of 11.........
who died an
Adrk Medical Center. Saranac Lake, NY
jPLACE) D I-,E G S)
rT.10 of person auti-ionzing
NaTfnd address oi;nearest livi;lg relative or r1a
Robin Mortensen-Miller 113yyjA jjd-, NY
Daughter ......
on I?iia to
27 SaranacAve_. , Lake id, NY
Nam,of Funeral Home.....�_±....Cl ark I Inc
12946
it
IMP(.RTANT pacefflaker in his or her
I spygnt sw in he best cA my Wvledg, the deceased Q5.()CED
hqcly.; (CIRCt-E ONE)
I U cad% t I have tile frill Doweraf)d authorization to an-Hf"ge for the crernation of the remains and
I -to d I remains. that.MY personal possessions have either been
ht�j the disposibOn Of the Uernate c.
re,mo I ved of May I)Ea destroyed, and agree Q protect defend and savp harmless Pine View
Q,Woun ymp any and all claim,13 and demands for b9F� or darrogos which may be made
again'.st thern by reason of or connected with be cmamuNj of said remains as directed, whether
or dempnds are or are w wholly groundless, false or fraudulent.
27 Saranac Ave,_.1_...L.a_k_e PIJaqkqe�. Ny _.12,946._
(WITN
Main St. , Lake Placid,
NY 12946
ID OF' R I,A,Tll,/E OR, I-. !W-T-77IT"i PI-ANO".-
3
11gJd an Uij�,