Olsen, Bjarne TO q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 4&0X (�,_
Name ;51A ME G Q SrN Case # Z�► L�
Date of Cremation ] -3 _ o � 4
Time Cremation Started a 14 yA"-N
Time Cremation Completed �V`w
Type of ContainerC'Qg,is- C�00i-aA CAG4Lf,+-- A3,t�hj
Remarks :
DISPOSITION OF CREMATED REMAINS
ereb direct Pine View Crematorium to dispose of the cremat
�1 Y
emains as follows:
Mail
to
Other arrangements - please specify: check here
If pulverization of cremate remains 1—sr equested,
POLICIES, RULES AND REGULATIONS
en for cremations 5 days a week 7:00
1. The crematorium will be op No Holidays or Sundays,
A.M. - 3:30 P.M. Monday-Friday. pre-arrangements by
y.
telephone
acce acceptancean be made
of remains tis necessary.*
telephone for P
Pine View .Crematorium is located a nsthe grounds of the Pine
View Cemetery, Quaker uaker Road, Town of Qu
ro erly signed by the nearest
3. An authorization for cremation rson stating that they do have
next of kin or other authorized p
he power and authority to arrange for the cremation of the
t P disposition of the cremated remains,
remains and to direct the
ossethions have either been removed or may e
that any personal p defend and save harmless Pine View
destroyed and agree to protect, loss Of
Crematorium from any and all claims and reason demands for
or r connected
damages which may be made against them by
claims or demands are, or are
with the cremation of said remains and/or disposition of said
w whether such c
remains as directed,
not wholly groundless, false or fit mustnaccompany athe oremains. in
addition to a regular burial perm
alternate
q. All remains must be encased lasmust orbeulofblcombustible
container. Caskets and containers
material. No Styrofoam or plastic containers will be accepted.
uestion relative to cardiac pacemakers must be answered
5. The. g
on the authorization to cremate form before the remains will e
accepted.
ated remains will
6.
Unless other arrangements are made ,nh the
days of cremation
be mailed eralRhomethandlingered .the Mail
service. There will be a $25.00
to the fun
charge for this service. Fee: Adult $300.00
Cremation, Administration thstool2s year
and $15 Recording 00 Infants (stillborn
Children (age 13
to 12 months) $100.00
* Additional $100.00 charge for crema one son done Saturdays 3�will 00 �be
Friday. Cremations d
Monday through remains received after 3:30
charged the additional $100.00 Any re
an additional $100.00.
P.M. Mon-Fri or Saturday will be charged
yql-b
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:
Bjarne S. Olsen Male
(NAME) t s (SEX)
9437 Shore Road, Brooklyn New York 11209
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 7th day of October 20 04
at Moses-Ludington Hospital, .Wicker Street, Ticonderoga, New York
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Ruth V. Olsen, 9437 Shore Road, Brooklyn, New York 11209
Relationship to deceased Wife
Name of 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)
certify that 1 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)
'x //&�
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date:_ 10- 7—D `f