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Hoyt, Harold rf-O WN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 47wr+h - �� ��Q�•,y,o �-� Name rl��v�d 4 Huy f' Case # �IS� Date of Cremation, 10 — 15—n1 Time Cremation Started 11:1O r Time Cremation Completed Type of Container Cl,,A-L GsKut ZEE 6w Remarks : IA^1«. ��• I S A It, Mu,. -ccl 12 : U U P.m a o P. i o o P- ( :ac) N , Cori do ('U o P�'1 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 made for Saturday. Pre-arrangements by telephone for acceptance of remains is necessary.* 2. Pine View .Crematorium is 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 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. 5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form 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 $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. TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745 -4 (if no Cemetery 745-44,76 76 answer) AUTHORIZATION TO CREMATE eguiatio The undersigned requests and a to its Rules and R uthorizes Pine View Cre ns to cremate the remains of matorium, in accordance with and subject e Ce 9 (SEX) (STREET) (CITY) _ (STAY (ZIP CO E) Who died on day of �O at 20 ©y (PLACE) CDR E'SS) c Name and address of nearest Irving relative or name of Person authorizing cremation: fill Relationship to deceased Name of Funeral Home _ �+ IMPORTANT t represent that to the best of my knowledge, the deceased�or a o ace body. (CIRCLE ONE) ho ao pacemaker in his or her 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, removed or may be destroyed,and agree to that any personal po�ssessW4 h4VV�x b"n 6ematorium from any and all Claims and demandfor JOS o dam�avges��may against them by reason of or connected with the cremation of Bald Y made s claims or demands are or are not whop remains as directed,whether Y groundless, false or fraudulent. 4TNE' S) (ADDRESS) Y (SIGNATURE OF R�1,,E OR LEGAL RE AND ADDRESS) ! /Z Sis' Signed on this dater