Lemery, Romeo rf-O` +N OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , h,it,
Name Aewn Case #
Date of Cremation lv , ig ��LI
Time Cremation Started R 6 t� fq—A-`
Time Cremation Completed 9 vn. A -
Type of C o n t a i n e r C,,yq \Z C) -V�161 L'44 2 C/
Remarks :
DISPOSITION OF CREMATED REMAINS
I hereoy direcr Pine View Crematorium to dispose of the cremated remains as follows.
t',1ai1 to
'31h4r al rang en',ents-please specify'
It pt_lver zation of cremated remains is requested, check here V
POLICIES, RULES AND REGULATIONS
1 1-he crematonuM will be open for cremations 5 days a week 7.00 A.M. - 3.30 P.M Monday-
-riddy No H011days or Sunaays, arrangements can be made for Saturday. Prearrangements
()y telephone ror acceptance of remains is necessary
"ine View Crematonum is located on the grounds of the Pine View Cemetery, Quaker Road,
own of ULieensbury
Hn authorization or 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 airect 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 V ew 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
rema ns 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
ourial permit '7-ust accompany the remains.
4 All remains crust be encased in a casket or suitable alternate container. Caskets and
conta ners must be of combustible material. No Styrofoam or plastic containers will be
accepted
3 he gaestion relative to cardiac pacemakers must be answered on the authorization to
cremate tcrm before the remains will be accepted.
6 Unless other arrangements are made the cremated remains will be mailed via Registered
U.S Mail within three days of cremation to the funeral home handling the service. There will
be a $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $225.00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to 12 months) $75.00
Additional $50 00 charge for cremations done aiter 3:00 P M. Monday through Friday
Cremarions done cn Saturdays will be charged the additional $50.00,
TOWN OF QUEENSBURY
PINE VIEW CEMETERY LN "I
& .1
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules anc Regulations to cremate the remains of:
(NAME) (SEX)
(STREET)
(CITY) (STATE) (ZIP CODE)
INno died on j� L day of
20
Elf �F/I / /9 GL L
(PLACE) (AD RESS)
Name and address of nearest living relative or name of person authorizing crematr n:
Relationship to deceased S150
Name of Funeral Home GGs00 � 'Qr9-C_
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 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.
(WITNESS) (ADDRESS)
9S �,J (l /v /Z g� 7;SIGNATURE F RELATIVE R LEGAL REP. AND ADDRESS)
Signed on this date: