Freiberg, Beatrice rl-
L O Y V N OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director i3kffiu, Mc Orr,.
Name 3neitrICA r1 . Frc Case #
Date of Cremation.. Iv — 1 — UH
Time Cremation Started 1 0 : .I q
Time Cremation Completed 1-00 t ,
Type of Container w00j Is-- di
Remarks : r 3D 1 ! �j
Mr,In �o J A . YYIuVPC� i qU Ads
P. q
Cc/dl �dw►n 1 00 �M
DISPOSITION OF Cp
,EMTED
SINS
Crematorium I hereby direct Pine View Cr m 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 crematoriumwill be open for cremations 5 days a week 7•
A.M. 3:30 P.M. Monday-Frida :00
arrangements can be y. No Holidays or Sundays,
telephone for acceptance of remainsor is r necessary.r*arrangements by
2. Pine View Crematorium is located on the
View Cemetery, Quaker Road, Town of Queensbury grounds of the Pine
3. An authorization for cremation properly signed by the n
next of kin or other authorized Barest
the power and authorityPerson stating that they do have
remains and to direct the disposition of the cremated or the n remains,
the
that any personal possessions have either been removed or maybe
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 745-4477(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:
(NAME) , , (SEX)
1312
(STREET) (CITY) (STATE) (ZIP CODE)
who died on /� day of �G'% � 202
at 7S _r /k/0
(P E) (ADDRESS)
Name and address of nearest riving relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral HomeLir-
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
S7,/
ims or dema s of holly roundless,false or fraudulent.
//Z2
TNESS) (ADDRESS)zl—
22
(SIGNATURE OF RELATIVE LEGAL REP.AND ADDRESS)
Signed on this date: `'