Olsen, Steven TOWN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4477
n/ Funeral Director ' -1� �.��
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e Of Cremation
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of Llie
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 cremationsRio 5 daysays or w ek : 00
A.M. - 3:30 P.M. Monday Friday
arrangements can be made for torday necessary•*Pre-arrangements by
telephone for acceptance of remains
2. Pine View .Crematorium Tolocated Queensthe grounds of the Pine
View Cemetery, Quaker Road,
3. An authorization for cremation properly signed by the nearest
next of kin or other author ozea range person
the cremag that tion ey cf lltthe
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 Prot all claims andct, fend save
ademalndsless for Pine loss View
of_
Crematorium from any an
damages which may be made against them by reason of or connect.
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, frial °ermit mustnaccompanyt. This athe°remains11 ill
addition to a regular bu P
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and
material. No Styrofoam or plastic containers containers will be acc Ptedlble
akers
ust be
nswe
5. The question relative to cardiac i remains awill rbe
on the authorization to 'cremate orm before the
accepted.
made the cremated remains will
6. Unless other arrangemen
be mailed via Registered U.S. Maits are 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
mdone son°ne after Saturdays will •be
Monday through Friday. Cremation
charged the additional $100.00 Any
remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
J
TOWN OF QUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(if no answer)
Cemetery 745A4.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance will)and subject
to its Rules and Regulations to cremate the remains of.
Steven John Olsen Male
(NAME) (SEX)
791 Vineyard Road Crown Point, New York 12928
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 1 th day of December 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:
Diane M. Olsen 791 Vineyard Road, Ticonderoga, New York 12883
Relationship to deceased wi f e
Name of Funeral Home Wilcox & Regan Funeral Home, 11 Algonkin St.
Ticonderoga, New York
IMPORTANT
represent that to the best of my knowledge.the deceased has or Lias rLo pacemaker in his or her
body.•(CIRCLE ONE)
certify that 1 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
,60malodUrn 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)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date:_ 12/1 5/2 0 0 4