Roberts, Arnold • ,f
r'-O(T4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director j3+'Z-te74 N1gVF-)2 ►v-'-T—
Name APgs4cj�,b ')-�ow17-1zt'C7 Case # 2 z 0
Date of Cremation - c,.- - 7'e;0 '-k
Time Cremation Started V p 14AI
Time Cremation Completed
Type of Container vxiQ Al V.l 9
Remarks :
10 Ps
9 3 5-A-11-.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 7464476
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:
(NAME) (SEX)
(STREET) (CrM (STATE) (ZIP CODE
who died on day of
��� �
(PLACE) (ADDRESS)
N me and address of nearest rivj*ng relative or name of person authonzin cremation:
Relationship to deceased
Name of Funeral Home
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 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
Cematorium 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
j7claims or mands are or are not wholly groundless,false or fraudulent
�J
(WIT (ADDR )
Ila
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: , �—'-q I ('�
DISPOSITION
I hereby direct OF CITED SINS
remains as follows: View Crematorium to dispose of the C
Mail toremate
d
Other arrangementsof
If Pulverization Please specify;
cremate remains
is requested
POLICIES , check here-.—
The
1• RULES
AID CATIONS
crematorium will be o
A.M. 3:30 P.M. Pen for cr arrangements can Monday-Friday. emations 5 days
telephone for be made for y• No Holidaysor week 7:00
acceptance of remain Saturday, Pre_ Sundays,
is necessary, * arrangements by
2• Pine View
View Cemetery, Quaker Road To nocated on grounds
Road the of the
3' An authorization Of Queensbury, Pine
next of kin for cremation
the power and Other authorized Properly signed b
remains authority to Person stating that y the nearest
that and t° direct arrange for they do have
any personal the disposition the cremation destroyed and Possessions have °f cremated °f the
either the
Crematorium agree to Protect been removed rains,
damages um from any and defend and save or may be
9 which all claims and harmless Pine View
With the may be made against demands for
cremation of said them b loss of
remains directed remains y reason of or connected
not wholly , whether such and disposition
addition t groundless, false or fraudulent.or °f said
regular burial demands are, or are
Permit must This authorization in
4 • All remains accompany the remains.
container, must be encased in a
material. Caskets and containers casket or suitable
No Styrofoam or must be alternate
plastic containers of °Ombustible
5• The question relative will be accepted.
on the authorization to cardiac
accepted, to cremate form before
must be answered
the remains will be
6• Unless other arrangements
be mailed via Registere are made the cremated remains to the funeral home Mail within three da s fcrewill
charge for this servicendling the service. There will be cremation e$25.00
$25.00
Cremation, Administration Costs and Recording Fee:
Children (age 13 months to 12 years) $150.00 Adult $300. 00
to 12 months) $100. 00 Infants
(stillborn
* Additional $100. 00
Monday through charge for cremations done after 3:00 P.M.
charged the additional Cremations
$100. 00 � done on Saturdays will be
P•M• Mon-Fri or Saturday will be chargeremains
an additi received after .
oval $100. 00.