Miller, John rl-0RN OF QUEEVBWKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,
Name T-,DPN & Vol C--,12 Case # t-1 I—) —
Date of Cremation� ro�..— ZO C y
Time Cremation Started , 2 ��6-) t
Time Cremation Completed 30
Type of Container x4P4-11') -z'
Remarks :
X:
C_'�G
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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:
If pulverization of cremate 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 remains to necessary.
by
telephone for acceptance
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
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
rization
not wholly groundless,agular burial permit must accompany th
re false or nt. This ae remains.o ill
addition to
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 crematerdiac pacemers form before the must be remains will rbe
ed
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered handlinS. 11 withi servicen three
Theredays
willobecae$25100
to the funeral home 9 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 Y.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100.00 Any remains additionadl $100 after 003. 30
P.M. Mon-Fri or Saturday will be charged an
I ' /
TOWN OF QUEENSBURY Y9J
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(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.
John R. Miller Male
(NAME) t t (SEX)
27 Mossey Point Road, Ticonderoga, New York 1.2883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 25th day of October 20 04
at his residence - 27 Mossey Point Road, Ticonderoga, NY 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Joan D. Miller, 27 Mossey Point Road, Ticonderoga, NY 12883
Relationship to deceased Wife
Name of Funeral Home Wilcox & Regan funeral home
Ticonderoga, New York
IMPORTANT
I represent that to the best of my knowledge,the deceased has or has no pacemaker 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
t iernatorium 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 demanca r are not wholly groundless, false or fraudulent.
.5
(WI ESS) DDRESS)
f
(SIGNAT E OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: 1 0/2 7/2 0 0 4 -