Ekseth, Marie C:) -A TOWN OF QUEENSBURY
Pine View Cemetery and Crentntnnuru
21 Quaker Road, Queenshnry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp uw%v\v queensbury net
Funeral Director:
Name of Deceased: 1A 1)0�" V71 K e"t4+
Case Number:
Date of Cremation: _ !Ef - 200 J
Retort: —r—A:F
T
Time Cremation Started: �1 p Aot A/\.
Time Cremation Completed: -L �;,,�1/ ✓�
Type of Container: CA\21) CI0'4M4) N( "7 f Q
Remarks:
None of Nnturnl Benttty ... A Good Place to Live
DISPOSITION OF CREMATED RE14AIIIS
hereb direct Pine View Crematorium to dispose of Llle c.reui��l.e�l
I Y
remains as follows:
Mail to ------
Maly" e ran----- s - please specifY - - —
If ulverization cremate remains is requested, ctleck Pere--
P
POLICIES, RULES AND REGULATIONS
for cremations 5 days a week 7 : 00
1 . The crematorium will be open No 11olidays or Sundays'
A.M. - 3:30 P,M. Monday-Friday. pre-arrangelliellL-s by
arrangements car. be made for Saturday.
telephone for acceptance of remains is necessary.* Life
2. Pine View Crematorium is located on the grounds of
View Cemetery, Quaker Road, Tow.' of Queensbury.
erly signed by Life nearest
3. An authorization for cremation rson stating that they do have
ropnext of kin or other authorized p
the power and authority to arrange for the cremation of the
remains and to direct the di have teitherf been removed the dor e may l,1-"
that any personal possessions
ct defend and save harmless
destroyed and agree to prote , P loss of
ine View
Crematorium from any and all claim sn and reason demands foror connected
damages which may be made against t Y
or ai-e
with the cremation of said such c /laims of deor i andstion are,of said
remains as directed, whether such
not: wholly groundless, false or fraumustnt.accompanyatheoremains ll in
addition to a regular burial permit
4 . All remains must be encased in asmust ketorbeulofblcombustible
container. Caskets and containers
material. No Styrofoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered
orization to cremate form before the remains will be
on the auth
accepted.
remains will
6.
Unless other arrangements are made ,th three days of cremation
be mailed via Registered U•S• thelservice. There will be a $25.00
to the funeral home handling
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $300. 00
Cr ears) $150.00 Infants (stillborn
Children (age 13 months to 12 y
to 12 months) $100.00 fter
* itional $100.00 charge for cremations on ote a
Sat urdays3�w l00 � Me
Add Cremations don
Monday through Friday.. remains received after 3: 30
charged the additional $100.00 Any
p.M.
Mon-Fri or Saturday will be charged an additional $100.00 .
I
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
• Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745A477(if no answer)
Cemetery 745A4.76
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:
_Mnr__i P F.kgt=fh Female
(NAME) (SEX)
. t
4 Monitor Park Road Crown Point, New York 12928
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 4th day of February 20 05
at Moses-Ludington Hospital, Wicker Street, Ticonderoga, New York
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Oed Ekseth 4 Moni i-nr Da k Rnad, Crown pni ntr 928
Relationship to deceased husband
Name of Funeral Home Wilcox & Regan funeral home
IMPORTANT
I represent that to the best of my knowledge, the deceased Lias or has no pacemaker in I]is 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
Id—re malodum 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: