Curtis, Valery TOWN OF QUEE�V/ BUQ Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 128D4
(518) 745-4476 (518) 745.4477
Funeral Director �'�
—e C��2�\ �J Caseff
')i Cremation
Cremation Started
' .—e Cremation Completed �G
. e o f Container�'il�s �-�J ✓�' Q ` �Z'- ZJ�'-�'�d
- _ •arks
AA ,
DISPOSITION or
I hereby direct CRIMMATED SINS
remains as follows: View Crematorium
�% to
P� � dispose of
the cremated
" G �<
O flier arrangements �A .Q G U
pulverization of cremate Specify;
., remains is requested,
, check here ►�
1• The crematorium � R�I+ES A� ��LATIONS
A.M. - will be
P.M. ° cremations
:30 Pen for
arrangements Monday-Friday. No 5 days a week 7:00
telephone for can be made for Saturday Holidays or
acceptance of y• Pre- Sundays,
for
is necessary, * arrangements by
2. Pine View Crematorium
View Cemetery, Quaker Road, is located on
Town of the grounds of the Pine
3. Queensbury.
An authorization for cremation
next of kin or other authorized properly
the power and authority to Person stating geed by the nearest
remains arrange for g that they do have
that° an and to direct the disposition the cremation
destroyed and anal possessions of the cremated remains,
Of gree to have either been removed or
Crematorium from Protect, defend and may be
doges which any and all claims Save harmless Pine
with may be made a and demands View
the be
against them b for loss of
remains °f said remains y reason of or connected
as directed, whether such claims
disposition of
not wholly groundless, said
addition to a r false or fraudulent. This
demands are, or are
gular burial permit must This Or
in
4• All remains must be encased in a cask accompany the remains.
container. Caskets and et or suitable alternate
material. No Styrofoam or containers must
Plastic containers will be acce be of pted.
5• The question relative to cardiac
on the authorization to cremate form on
must be answered
accepted, before the remains will be
6. Unless other arrangements are made the cremated remains
be mailed via Registered U.S.
to the funeral home handling. theil within
The edays Of cremation
charge for this service.' be a $25.00
Cremation, Administration-Costs and Recording Fee: Adult 30
Children (age 13 -months, to 12 years) $150.00 Infants $ 0.00
to 12 months) $100.00 •* (stillborn
* Additional
Monda $100.00 charge for cremations done after 3:00 P.M.
y through Friday. } Cremations done on Saturdays will be
charged the additional
P.M. Mon-Fri or Saturday will00 be charged ans received additional
after . 30
oval $100. 00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(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:
(NAME) t (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 11 t h day of January 2
at 44 Mare Rr3 . r auP Pl ar-; r3; bry 1 ?946
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Zay B. Clzrtis, rT -
Relationship to deceased / 05-X ,tJ
Name of Funeral Home , �� (✓Lf�l i A-)
27 Saranac Ave. , Lake Placid, NY 12946
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
,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
such claims or demands are or are not wholly groundless,false or fraudulent,,
27 Saranac AvP T alra • ni ar•; d _ Iry 1 2046
(1MTNESS (ADDRESS
4 Marcy Rd. , Lake Placid, NY 12946
SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: q/a'a