Vemette, Margaret TOWN
OF QUEENB U'P J
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director .-11
a-e- �t��wllZF� �l�/�t ;y / _Cases I c1
_ a 1 . Cremation - 1 0C' � -
-e Cremation Started
-e Cremation Completed C?
- . se of Container G' a-J �'� `���y /b/''4'
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DISPOSITION OF CREMATED REMAINS
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\ hereby direct Pine View Crematorium to dispose[fthe cremated remains asfollows: �
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Mail to
Other arrangements-please specify:
if pulverization of cremated remains is requested, check here
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POLICIES, RULES AND REGULATIONS
The crematorium will b� opon for onarDadons 5 s a week 7:00/�K8� - 3:30 P.M. K�odday-
�«t Fh
1 e cr�nnUd�ys or �undoy�. �nangan�e ts —can ba nnade for Saturday. Prearnabgoments
--' o Ho necessary.
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by telephone for acoaptmnceufnonainsis .2. pj � �
0�vuJ�w� ato� nn� is located on the QnOVndS of the Pine View Ceme&ary, C>uakorf(oad,
ToWn` ofQueansbury �|
3 An authorization for oren�a\onproperly signed by the nearest next cf kin or other a
ufthbrized
� person stating that they do have the power and authority to arrange for the unamet| of the
Pa remains and b] direct disposition of the cremated [emains, that any personal poseessm
� ^ nynnoestimeyed and agree defend U e
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have o*���oev» /e^=«=" "' i^°' ~~ - ��daU �|a� sa'd�d�mondef�rl�aa ee
harmless Pine Via�Crematorium �o[n any un xo .. c d _
o[ h b no�deagainst them reasonoforoonnectodvvUhtheononlaUonc�ao/ d
«vh\« may dispositinn of by
as dic�otad. whether such n|oinls orde�ndn |s are,
remainsan /or d\ ha|a= remains
This in add�ioOto �'ns�ua/
o[are not vYho\� groun eSa. false or �
' burial permit must accompany the remains.
t rau�ab a|hsnn�b*Conta\Dor Caokes and
� �� be � msed \nacae�a n '� �
4 Al � '«����u ^ ' --'-- | hccontainersvv e
. w '°'' - `. �wnfhuebb� maheriai NoSh/nofoamorpas .
5 The quecardiac pacemakers must be answered on the authorizatiQh to
cremate fo[�Nbefore the remains will be accepted.
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6 Unless other arrangements�angenlents are made the cremated remains will be mailed moRe leroo
� U Mail within three days of cremation to the funeral home handling the service. /n.ere vviU
- _b ' $20.00 charge for this service.
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Cremation Administration Cos a and Recording Fee: Adub$225.UO Children (age 13 �nfhs to
12 years) '115.00 Infants (stillborn to 12 months) $75.00 �
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' ^ � /kddmpmsL$�u uJ ".~ .__ftsr 3 OO P.M. Monday through Fhdoy��
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ad the additional $50-00,
Cnsnsd|ons done on Sam/days w"x be nhnH" `
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TOWN OFOUEENS8URY !
PINE VIEW CEMETERY i
& �
CREMATORIUM '
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Quaker Road, Oueenebury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
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Cemetery745-447G
AUTHORIZATION CREMATE
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The undersigned requests and authorizes Pine View Crematorium, in accordance with doubject
fo its Rules and Regulations no cremate the remains of: y �
(STREET) (CITY� (STATE) (ZIP CODE) f:
-�4
at Ai L
LACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
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Relationship to deceased
Name of Funeral H
/Z r--
I[NPORTANT
| neprement that to the best ofrny knowledge, the deceased has ooernakerin i� orher
body. (CIRCLE ONE)
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I certify that I have the full power and authorization to arrange for the cremation of the rqimains 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 Vif,aW
Crematorium from any and all claims and demands for loss or damages which may be Tade
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. d
(WITNESS) (ADDRESS)
---MIGNATURE OF RELATIVE OR LEGAL REP. AND ADURESS)
Signed on this date: L9/
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