Densmore, Elizabeth rl-O OF QUEEN
,s5BU99 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name y� 2 W b �i-I-� �l�l�� i-z. 1=� Case # 3 1
Date of Cremation
Time Cremation Started
Time Cremation Completed l �� �� ✓�
Type of Container
Remarks :
-i=F
a �
0
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
5days ays or week
Sunday00
A.M. - 3:30 P.M. Monday-Friday. prearrangements by
arrangements can be made for Saturday.
telephone for acceptance of remains is necessary.
T
2. Pine View .Crematorium located on the
grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
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 et dis arrange
or the of the cremated remainsof e
remains and to direct P
that any personal possessions have either been removed or may be
destroyed and agree to protect, defend a and and ademandsve less for P loss ne lof
Crematorium from any and all claims
damages which may be made against them by reason of or connected
with the cremation of said remains
cla claimsand/or
or demands are, or care
aid
remains as directed, whether such rizatio
not wholly groundless, false ° fraudulent.
accompanyatheoremainsn in
addition to a regular burialpermit must
4. All remains must be encased in a casket or suitable alternate
ners must be of container. Caskets and coai containers will be acceptedlble
material. No Styrofoam o plastic
5. The question relative to cremate form pacemakers
efo ek the remains will answered
be
on the authorization to
accepted.
6. Unless other arrangements are made h threemated remains will
days of cremation
be mailed via Registered U.S. Mail within
to the funeral home handling the service. There will be a $25.00
charge for this service.
0-00
Cremation, Administration oo 12s r Recording 0g0 Fee: Adult
(stillborn
Children (age 13 months t years)
to 12 months) $100.00
* Additional $100.00 charge for emations cremations
son o Saturdaysne after 3�will 00 �be
Monday through Friday. Cr remains received after 3:30
charged the additional $100.00 Any
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
41 .
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
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:
i ^b.^i-h S 17PnGmnrP Female
(NAME) (SEX)
228 NYS Rt. 9N Ticonderoga New York 12883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 31 s t day of July 20 04
at Moses-Ludington Hospital, -Wicker Street, Ticonderoga, NY 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Graydon Densmore., 341 Champlain Avenue, Ticonderoga, NY 12883
Relationship to deceased Son
Nameof Funeral Home Wilcox & Regan 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
,.Crematorium from any and all daims 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.
(WITNESS) (ADDRESS)
SIGNAAJIRE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: