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Blair, Wayne TOWN OF QUEENSBURY Pine View Cemetery nod Cretttn tort It ltt 21 Qunker Rond, Queenshury, NY. 12804.5902 (518) 745.4476 (518) 745-4477 http //w\v-,v queensbury nel Funeral Director: :)4 1.1-,'Fo Name of Deceased: U M(7— i3k, Y2Yti �Z Case Number: 61 1 Date of Cremation: — ZG c Retort: (Z- R 10(w �y M Time Cremation Started: /V-% Time Cremation Completed: / IBC Type of Container: �9 Y1�`��- C,- OL, ► kl CA-6 Remarks: � So vim, Ho nc' n/ NnturnI B e n i i A Cnn f Plnie to Live I r 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 for Saturday. Pre-arrangements by telephone for acceptance of remains is necessary.* 2. Pine View .Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 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 -&re not wholly groundless, false or fraudulent. This authorization in, addition to a regular burial permit must accompany the remains. 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 cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6. Unless other arrangements are made the cremated remains will be mailed via Registered U.S. Mail 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 done after 3:00 P.M. Monday through Friday. Cremations done , on Saturdays will be charged the additional $100.00 Any remains received after 3:30 P.M. Mon-Fri or Saturday will be charged an additional $100.00. TOWN OF QUEENSBURY QINE 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 requesL%and authorizes Pine View Cnematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: (NAMED t . (SEX) 0 (STREET) (CITY) (STATE) OP ) who died on ©L< day of 20 _ at L 1 aga l (PLACE) (ADDRESS) Name and address of nearest firing relative or name of person authorizing cremation: j I . ( �> ELF La) Relationship to deceased -J Name of Funeral Home, P� i IMPORTANT 1 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 edher been removed or may be destroyed,and agree to protect,defend and save harmless Pine View drematodum 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) l 28o'f . �(SIG�NATUREOFRE TIV �LEEGAREP-AND ADDRESS) Signed on this date._ .