Centure, Jennie "'AWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / C) 1 5 0 ! y
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Date of Cremation -Zoo
Time Cremation Started rj ig
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 7454476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate there re f:
-mains o
(NAME) t t (SEX)
/'�:— -C'e C/0"P7,47—
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 6—day of V L-t �� 20,
at W,:v sc-�-/(
(PLACE) (ADDRESS)
Name and address of nearest riving relative or name of person authorizing cremation:
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Relationship to deceased 1>
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge,the deceased has maker 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 prated.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
such claims or demands are or are not wholly groundless,false or fraudulent.
( TNESS) (ADDRESS)
(SIGNATURE OF RELA E OR LEGAL REP.AND ADDRESS)
Signed on this date:
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 cremate 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 de for
tance of remains tis dnecessarye*arrangements by
telephone for acce p
2. Pine View r Road, Town of Queensbury.
Crematorium °cated on the grounds of the Pine
View Cemetery, Q
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 of
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.
The rardiac beforeers m
ust e answered
o i
on the authorization to cremate form the remains will be
accepted.
6. Unless other arrangements are made the cremated remains will
l within
be maieled via funeralRhometered handling.thelservice. three
Theredays
will°be cremation
$th
to the 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 $100.00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100.00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
�Z,
TUNISON FUNERAL HOME
105 Lake Avenue
Saratoga Springs, NY 12866
(518) 584-0440
BODY DELIVERY RECEIPT
(Required by Section 4145 - NYS Public Health Law)
A.NAME OF DECEASED PERSON: ?,).
(as it appears on burial,cremation or transit permit)
B.DATE THAT BODY WAS DELIVERED: _ 6
C.NAME AND REGI/STRATION NUMBER OF FUNERAL DIRECTOR MAKING DELIVERY:
(Print Name) (Reg.#)
D.NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
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(Print Licensed Funeral Firm Name)
E.NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSITION WHO RECEIVED THE BODY:
(Print Name)
CHECK(✓)IF NO ONE IN CHARGE
F.NAME/LOCATION OF PLACE OF FINAL DISPOSITION:
47i t
(Name) (City,State)
(SIGNATURE of Funeral Director) 616NA&URE of Person Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Pink Copy-Decedent's Family