MacDonald, Donald rf-O%N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Di ector M �
/� �� ' `
Name ^ ,' 1' ! i9a)dt'd& � Case # Z
Date of Cremation q ? 2G7G
Time Cremation Started 0, 15 tj A
Time Cremation Completed
Type of Container Cktn-d '�3d iz �� ��� 0 70 f---'Z
Remarks :
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the crG�m ted
remains as follows: ,
Mail to ._L'L_� C<-Art2-7 JAILAA14- Ave.,
-%
Other arrangements please specify:
If pulverization of cremate remains is requested; check here '7
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 SunOaiys,
arrangements can be made for Saturday. Pre-arrangement'oSi by
telephone for acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the �'P;ine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the neriast
next of kin or other authorized person stating that they do `1�h' ve
the power and authority to arrange for the cremation ofJ he
remains and to direct the disposition of the cremated rem4itis,
that any personal possessions have either been removed or max; be
destroyed and agree to protect, defend and save harmless Pinef,Yilew
Crematorium from any and all claims and demands for los ' of
damages which may be made against them by reason of or corm ,cted
with the cremation of said remains and/or disposition of rjs, id
remains as directed, whether such claims or demands are, or, are
not wholly groundless, false or fraudulent. This authorizatiopl in
addition to a regular burial permit must accompany the remains;:.
4 . All remains must be encased in a casket or suitable altef'p&te
container. Caskets and containers must be of combust,�ible
material. No Styrofoam or plastic containers will be accepted';
5. The question relative to cardiac pacemakers must be answered
on the authorization to cremate form before the remains wil.' !be
accepted.
6. Unless other arrangements are made the cremated remainsall
be mailed via Registered U.S. Mail within three days of cremation
to the funeral home handling the service. There will be a $2."�.Io0
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $300.0, 0,
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
Monday through Friday. Cremations done on Saturdays wily 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.
f
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'TOWN OF QUEENSBURY
PINE VIEW CEMETERY
& 111 I'
CREMATORIUM PR
N
Quaker Road, Queensbuty, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
rlr
The undersigned requests and authorizes Pine View Crematorium, in accordance with r
N-1. subject
to its Rules and Regulations to cremate the remains of:
ewAL.1-9 A/A
(NAME:) (SEX)
)tA-1),A/c J-01,t /V y >1 '1'
(STREET) (CITY) (STATE) (ZIP CODE)
who died on ..—. day of
at-
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation-
Mrs Joan Macdonald 1491 Bonnier View Road, Wilmingtot ,i�
New York 12997
1i i f e
Relationship to deceased
Name of Funeral Home
4 A 14
iI
IMPORTANT
I represent that to the best of my knowledge, the deceased has oKI ianpacei maker ire,ks" or her
q�
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the rtiTlains and
to direct the disposition of the cremated remains, that any personal possessions have 01 h�(.�Ir been
`
removed or may be destroyed, and agree to protect, defend and save harmless Pine V-
Crematorium frorn any and all claims and demands for loss or damages which may be Alllde
against thern by reason of or connected with the cremation of said remains as directed,4kether
such claims or demands are or are not wholly groundless, false or fraudulent.
IOLA
1)1L_Vz A/2 '161
(SIGNA'n.JIRE OF RELATIVIH OR LEGAL REP. AND ADDRESS)
9 7
Signed on this date: 14-/17' 41 2 0