Pratt, Shirley C:) -.A TOWN OF QUEENSBURY
Pine View Cemetery and Cremn tort 11M
27 Qunker Rond, Queenshury, NY. 12804.5902
qlamw (518) 745.4476 (518) 745-4477
htrp//w%vNv queensbury net
Funeral Director: I,3 C---I
Name of Deceased: "(o "� —
Case Number:
Date of Cremation:
Retort: G_1�-4 I'-) 0 t�J
Time Cremation Started: U �`
Time Cremation Completed:
Type of Container: �iA�Z� �C71�i� C/ /Lj t L�
Remarks:
" Nome o/ Nnturnl Beauty ... A Cooit PInie to Ltue "
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DISPOSITION OF CREMATED REMAINS
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| hereby direct Pine View Crematorium to dispose of the cremated remains as follows'. � !
Mail to M o Clark,Other arrangements-please specify'.
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|f pulverization of cremated remains s requested, check here__-_-_ . .
POLICIES, RULES AND REGULATIONS
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week �3OP �� ��hday-
atohumvvd\ be open for crenladons5 days awee � A.M.� - � P.M, �s
1 Theor�nnoHoUd�yaor3undoy�. a�angenlen� can ben�ode for Saturday, Praorrahgpmen
Friday. ..
by telephone for acceptance of remains ioneceasary.
2. P|neV|evVCrernahohumis \oo@tedonthegroundsoftheP\DeViewCametery. {Jua rROad.
Town ofC]ueensbury. �
�r�ed
authorization for nlah�npnopedy �ignedbythenearestnex cf kin or other e of the
save-
harmlesser and authority to arrange for the cremati
person stating that they do have the pow
ion of the cremated remains, that any personal possessions
remains and to direct the disposit
^ Pine View Crematorium from any
on oforconnected with the ue"="=. ~,a'-
whiohrn�ybennadeagam��tham �ynaaa a directed whether such �aimmo'de��c�doare,
n*nnoinsond /ordisposition »f��\drenno|n� a t This `udhor\�ation �n �dd�oOhoa�eQ«|or
orar8no1vVhnUyground\eas. faiBeor��u�u\en � u
burial permit must accompany the remains.
uo d
4 All remains must be encased in a casket or suitable alternate Cnnta\ne[ Caske�
buet/bie material. No Styrofoam or plastic containers " i\l ~
be
containers must be of:om
accepted. ,
5 The question relative to cardiac pmcernakera must be answered on the authohza�ob to
cremate form before the remains will bo accepted.
e cremated remains will be mailed via R
G Unless other arrangements are node th \ home handling the service. !:'There ,will
U.S. Mail within three days nf cremation to thnfunara
be g $20.00 charge for this service. �
Cremation, Administration Costs and Recording Fee: Adult$225.00 Chi|dna� (age 13��ondls to
' 119 OO Infants (stillborn to 12 months) $75�DD
12 years) � � n )
~ Additional $50 OU charge fo
(� r oibmeUuns done after 3:00 P.M, Monday through Fr\da�,Cremations don' on Saturdays will be charged the additional $60-00. �!
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TOWN OFOUEENG8URY |
PINE VIEW CEMETERY �
CREMATORIUM
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Quaker Road, C)ueemebury. New York 128O4
Phone (518) Crematorium 745-447T (if no answer)
Cennetery745-447G �
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�AUTHORIZATION TOCREMATE
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The undersigned requests and authorizes Pine View Crematorium, in accordance with abld.subject
to its Rules and Regulations to cremate the remains of-, �
SHIRLEY N. PRATT Female
(STREET) (CITY) (STATE) (ZIP COFE—) "
who died on 9th day of
at(Jihlein Mercy Center, Lake Placid, NY
- (PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation: |
,
Gordon
Relationship todeceased
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Name of FuneralH
2945 l " ^,^
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A IMPORTANT
| represent that to the best ofmy knowledge, the deceased has orhas no pacemaker in isl 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 el'ih6r 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 rna de
against them by reason of or connected with the cremation of said remains as directed '�Vhether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGOWTORE OF RECATIVE OR LEGAL REP, AND ADDRESS) 12946r.
Signed on this date: �
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