Rooker, William TOq4/N OF QUEEN
,s5B` JKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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' : Te Cremation Completed
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the c:rematud
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 io 5 daysays or we Sundays,7 : 00
A.M. - 3:30 P.M. Monday-Friday. o
Pr -
arrangements can be made forremains tis necessary•*arrangements by
telephone for acceptance of rem
2. Pine View Crematorium
s locat.ed on
of Queensthe grounds of the Pine
r
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
isposition of the cremated remains,
remains and to direct the d
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 oor con loss
Of
damages which may be made against them by reason
ed
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,aregular burial permit must naccompany t. This athe o rization ill
remains.
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 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 in U.S. withi tTherehree dwillays obecae$25100
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 Any ed an additional $100 after 003.30
P.M. Mon-Fri or Saturday will be charged
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Plione(518)Crematorium 745A477(if no answer)
Cemetery 745A4.76
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:
William Edward Rooker Male
(NAME) (SEX)
14 Ell Street Ticonderoga, New York 12883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 2nd day of December 20 04
at his residence - 14 Ell Street, Ticonderoga, New York 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Juliann Rooker, 14 Ell Street, Ticonderoga, New York 12883
Relationship to deceased wi f e
Name of Funeral Home Wilcox & Regan Funeral Home, 11 Algonkin St.
Ticonderoga, New York 12883
IMPORTANT
I represent that to the best of my knowledge,the deceased has o ias pacemaker in his or her
body.•(CIRCLE ONE)
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
di rnalorium from any and all daims 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)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: 12/3/2 0 0 4