Walter, Norbert OF QUEEN 21-Wy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directora�j� ���
a-e Z)/o(7,o6 to 19I,76/?— Case;: l 7 L
are 01 Cremation
' =tee Cremation Started
. , e Cremation Completed
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remarks
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 The crematorium will be open for cremationsa ifo0r Saturday.OPre-arra�gements
Friday. No Holidays or Sunday arrangements can be made
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.
n or other
zed
3. An authorization for cremation
haveproperly
the power andbau authority to arrange for y the nearest next of s the cremation hoflthe
person stating that they d personal possessions
remains and to direct the disposition of the cremated remains, that any p
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 then by ema reason
as directed, whether nnected such claims the lon of or demands are,
remains and /or disposition of s
or are not wholly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
uitble nd
4. All remains must be encased inamaterial. No Styrofoam
casket rsalt e container. Caskets
il
or plastic containers swl be
containers must be of combustible
accepted.
5. The question relative to
remains cardiac s pacemakers
will be accepted.be answered on the authorization to
cremate form before the
6. Unless other arrangements are made
the
cremated remains will b miled via o the funeral home handengahe seryice.gTheredwill
U.S. Mail within three days of cremation
be a $25.00 charge for this service.
g Fee: Adult$300.00 Children (age 13 months to
Cremation, Administration Costs and Recordin
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.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
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:
T-LR,
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
EL _
who died on _ day of /`� f c / 20 0-/-/
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
- l
f /z_t' i o� �a J� —
Relationship to deceased 1��'
Name of Funeral Home / U �'d ��
IMPORTANT
I represent that to the best of my knowledge, the deceased has r ha no p cemaker 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 of or connected with the cremation of said remains as directed, whether
h clai demands are or are not wholly groundless, false or fraudulent. 2_6� (�
(WI SS) (AD`9�/ I/--D SS)
t6_
(SIGNATURE OF RELMFIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: IfVrl Z