Doyle, Betty 2r0RN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Vf-NtLj 0
Name i„��V � Case #
Date of Cremation 1 — �p - __Z�o t-1
Time Cremation Started 2 Iq '^_\'
Time Cremation Completed
Type of Container c' 4y_j &741 N �3/rit
Remarks :
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify:
g: l
If pulverization of cremate remains is requested, check he e
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 g a regular burial permit must rodless, false or naccompany t. This athe o rization in
remains.
addition to a
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.
ust be
5. The question relative crematediac pacemers form before the m remains will rbe
ed
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Regtered handling.the Mail
servicen three
Theredays
willobecae$25100
to the funeral home
charge for this service.
Cremation, Administration Costs and Recording Fee: Adul $300.00
Children (age 13 months to 12 years) $150.00 Infants (s
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 745-44.76
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:
BETTY D . DnYI F FEMALE
(NAME) t , (SEX)
62 SLY POND RD . , FORT ANN , NEW YORK 12827
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 3RD day of DECEMBER 20 04
at GLENS FALLS HOSPITAL , GLENS FALLS , NY. 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
PHYLLIS CLEVELAND , 119 SO . IKE HAYES RD . , BRANT LAKE , NY. 12815
Relationship to deceased SISTER
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT
I represent that to the best of my knowledge, the deceased has as n cemaker 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
ematorium 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.
P .O. Bnx 277 FORT ANN , NY . 12827
(WITNESS) (ADDRESS)
'���
(SI15NATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: DEC . 0 5 , 2004