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Zaba, Walter rmrwN OF QUEENB`Z.1r Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director a e V4hT 12, yT Case;- �, [.c �a : e Of Cremation 12 - Z2.. _ -L� Cremation Started l y 14✓Vl e Cremation Completed e of Container C,,1rAe-Q `' o4z(" A W-rNkA— t �_�arks Xs- A l JJ� 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 cremated remains is requested, check here 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. Prearrangements 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 ohaveroperly the powernandd a thority to arrange a ge forl by the nearest next of the cremation or other hoflthe person stating that they 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 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 pacemakers must be accepted.be answered on the authorization to cremate form before the remains mailed via 6. Unless otherarrangements in three a dayssofre made the cremated remains will cremation to the funeral home handling the servicce.gThe There U.S. Mail within three day be a $20.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult 4,_:".`- Children (age 13 months to 12 years) $115.00 Infants (stillborn to 12 months) $75.00 Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50.00. TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (if no answer) Cemetery 745-4476 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: (NAPE) (SEX) 4 C4 4A iNA, 4-4 4/%V� N, P (STREET) (CITY) (STATE) (ZIP CODE) who died on Z day of � U 20 3 '4 at (PLACE) (ADDRESS) Name padWaddr ess of nearest living relative or name of person authorizing cremation: Relationship to deceased � '� i Name of Funeral Home (tp cx-\ I IMPORTANT I represent that to the best of my knowledge, the deceased has r has no 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 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 succ�h)) o�ddmands claims are or are not wholly groundless, false or fraudulent. (WITNESS) (ADDRESS) `� S / lZ ©� (SIGNATURE OF LATIVE OR LEGAL REP. AND ADDRESS) / Signed on this date: 1 �I R � l 1 6