Thayer, Jack r'-n J+N OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorP, Z -S FEC,4A
N a m e1A 6,1k t4, k, XZ Case
Date of Cremation
Time Cremation Started
Time Cremation Completed V-AA
Type of Container O,) C ky kcr ij 3 4 .4-v
Remarks :
�� �� 41
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
Ho 5 daysays or weekSun 7 :00
A.M. - 3:30 P.M. Monday-Friday.
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.
2. Pine View Crematorium s located on
Queensthe grounds of the Pine
View Cemetery, Quaker
3. An authorization for cremation properly signed by the nearest
authorized person stating that they do have
next of kin or other
to arrange for the cremation of the
the power and authority
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
such claims or demands are, or are
remains as directed, whether
fraudulent.or authorization
o in
not wholly groundless,bfalse permit must accompanytheremains.
addition to a regular
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 cardiacto form before the must be remains willrbe
ed
on the authorization to cremate
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered in U.S. withi tTheredwillobecae$25�00
to the funeral home handl g the
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 char charged an additiona remains l $100 after 003.30
P.M. Mon-Fri or Saturday will be g
J Z
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(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
Jack S. Thayer Male
(NAME) tit (SEX)
1395 U.S. Rt. 9, Box 14, Severance, New York . 12872
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 30th day of November 20 04
at Moses-Ludington Hospital, Wicker Street, Ticonderoga, NY 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Audrey D. Thayer, 1395 U.S. Rt. 9 Box 14 Severance, NY 12872
Relationship to deceased wi f e
Name of Funeral Home Wilcox & Reaan 11 A gonki n st. p .Ti condProga, NY 12883
IMPORTANT
1 represent that to the best of my knowledge,the deceased bas or as n pacemaker in his or tier
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
,dr-e matodum 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)
(SIGNAT E OF RELATIVE OR L GAL REP.AND ADDRESS)
Signed on this date: