Cavezza, Elizabeth . (-rnq+N OF QUEEN5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (Y\ � C/*KA\� I�
Name C rl_1)\y) a,4-4 elk, /I-Ir')-rL f1f Case # Ll 2 Q
Date of Cremation Li --I cc, LA
Time Cremation Started `1 ✓,C An
Time Cremation Completed l Ll
Type of Container Ca
Remarks :
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�^ DISPOSITION OF CREMATED REMAINS
oMuro to dispose of cremated remains as follofollofollows'.i hereby direct Pine View Cnannet
Mail to IAIC
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Other arrangements-please specify, �
if pulverization of cremated remains ie requested, check here
POLICUES, RULES AND REGULATIONS �
1 The rennatonunnwiD be open for crernadons 5 days 8 week 7�DOA.KX. - 3:30 P.M. K�odday-
mc N� Hn|id�yaorSundaya. ��angecnentsconbemodeforSatunday. Prearrabgpcnents
Fri
day. t nce�fnama\ns |oneoe�e�ry ' .�
byte|ephonaforaocep«a � i
2 Pin�Vi�vVCrern�0ori�mis \0o8Uad0ntheQr�V��� uft�� P\noVi�� C�m�tary. OuQ��rR0ad,
Town of{]ueensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other ault o
g that they do have the power and authority to arrange for the cremati �'n of the
person statin ny personal possessions
remains and to direct the disposition of the cremated remains, that a .1
or may be destroyed and agree to protect, defend and save
have either been removed J ;
harmless Pine View Crematorium from any and all claims and demands for loss or(,.arflaytb
which may be made against them by reason of or connected with the cremation of s"aid
remains and /u/ disposition — said remains
. d |anL Th\a �udlohzo�onm �UU¢mDnoa'! '
�Uv/�
o[are not vVho|Ngroundless, false cr��u u �
burial permit must accompany the remains.
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must be �no�se� inac�ska�orsu�a�\� a|\ern�teContainer� Casket a��
4 All remains r»ua be mabaria|� No Styrofoam or plastic containers vvii�b�
containers must e
accepted. | ,
5 Thequasdonrn|ativeUxoardianp�cennaKersmuo� beon�moredonthe �uth0h to
� cremate form before the remains will be accepted. �
are remainsmU| be mailed via Registered
G. Un\esa »thera�ang*monts
n��ti�ntoih� fuOaos\ h0npeh�ndUnQthe service. ere will
U.S. N1oi| within threedaysofCns
be $2O.00 charge for this service. �
Cremation, Administration Costs and Recording Fee: Adu|t$226.D0 Children (age 13,!n9nthsho
� 0O Infants (stillborn to <
12yaorn) �11 ( � �
° Additional $50'00 charge for cremations done aftor3:O0 P.M, Monday through Friday, '
Creations done on Saturdays will be charged the additional $5U-0O. �
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� TOWN OFOUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
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Quaker Road, C)ueenabury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
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Cemetery74S-447G `
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AUTHORIZATION CREMATE' !
The undersigned requests and authorizes Pine View Crematorium, in accordance with andmub]ect
to its Rules and Regulations to cremate the remains of: ^ /
(STREET) (CITY) (STA-ME) (ZIP CODE)
who died on 25th �0
day of
at— Bartlett CaOey Rd. , Twn of Harrietstown, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship todeceased
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Name ofFuneral Ho
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IMPORTANT
| represent that to the best o[my knmw|edge, the deceased has cenlaker|n i§ or her
body. (CIRCLE ONE)
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! certify that | have the full power and authorization to arrange for the cremation of the rqp6ins and
to direct the disposition of the cremated remains, that any personal possessions have el",,thbr been
removed or may be destroyed, and agree to protect, defend and save harmless Pine W�W
Crematorium from any and all claims and demands for loss or damages which may be rniade
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.
27 Saranac Ave. , Lake Placid, NY 1��46
TN 'ADDRESS)
IGNATURE OF RELATIVE OR LEGAL REP, AND ADDRESS)
Signed on this date
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