Layfayette, Cecilia TOWN OF QUEENSBURY
Pine Virtu Cemetery and Cremntortmrt
27 Quaker Road, Queensbttry, NY. 72804.5902
(518) 745.4476 (518) 745.4477
http //ww\v queensbury net
Funeral Director: �J- 1�7U
Name of Deceased: Ci 12— t-- 1 R /A P FPO &11-
Case Number: 120
Date of Cremation: ), • S Z0t9 X
Retort: F
Time Cremation Started: 11-!S
Time Cremation Completed: q0
Type of Container: GrZ10.:1l (!,r"U Jk N Ct6A�[SA- ✓a-+ '��
Remarks:
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Nome of NalnrnI Beauty ... A Good PInie to Live
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~ DISPOSITION OF CREMATED REMAINS
hereby diir,ct Fu raw C,ematonWnl to dispose of the cremated remains as follows.
r.la�i tc,
Other e11reirts ijlec.]se specity —
;'t,l` ei =anon of cremated ,-emains is requested, check here
POLICIES, RULES AND REGULATIONS
I Ise crematorrurrr �^gill be open for cremations 5 days a week 7:00 A M
/ eel No Ho�iclays Or SLIHdays, arrangements can be made for Saturday3p P� Monday-
Iw tclepfiune for �lccepc.rnce or remains is necessary Prearrangements
r'e Vltw Ciemafentun is located on the grounds of the Pine View Cemete
�wn or � ;ecnsbui
} ry, Quaker Road,
ruth anon ror cremation properly signed by the nearest next of kin or other
ersc n staung that they do have the
clirrs and to chest the disposition of the cremated remains, that f Personal authorized
Power and authority to arrange for the cremation of the
I ave eithe) t een removed or may be destroyed and agree to protect, defend and
Ira;nilr'ss {'ure �/ Y p onal possessions
C=rematorrum from any and all claims and demands for loss or damages
cl; may be made against thern by reason of or connected with the cremation of said
rerna ris pan
d /or a�sposition of said remains as directed, whether such claims or demands are,
or air' riot wholly r_I,c,Unciless, false or fraudulent This authorization in addition to a regular
c anal perms n-ust �lcconrpany the remains,
g
rern<�ins must be encased in a casket or suitable alternate container. Caskets
I; rta.(0d usl hr of combustible material No Styrofoam or plastic containers will be
�rceepteq kets and
e y_,estion relatne to c;]rdiac pacemakers must be answered on the authorization to
crerr�atr form befo�ie the remains will be accepted.
Unless other �t- ia c;- ,
leinents are made [lie cremated remains will be mailed via Registered
U S Mail wrlhin three days of cremation to the funeral home handling the servic
be a ^'U 00 ;barge ror this service e. There will
enr,t,un, Aar7rinis[ra[ion Costs and Recording Fee: Adult $225.00
I` years) 4 115 00 Infants (stillborn to 1� months) $75 00 Children (age 13 months to
�udiuun it :a50.00 charge for cremation
Crarnanuns ciorie on Saturda s clone after 3.00 P M ys v;ll be charged the additional $50Monday,0o, through Friday
TOWN OF OUEENSBURY l
PINE VIEW CEMETERY
CREMATORIUM
Uuaker Road, Oueensbury, New York '12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned reduests and Eluthorizes Pine View Crematorlllrn, in accordance with and subject
to its Rules and Regulations to cremate the remains of.
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
1.1/1ho died on day of 20 6 S_
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
11A/�'�Nam_- x. p j li 64 Vrr S J 7hc -e/ l� A ��Lta c � &1 7
Relationship to deceased �'���'f'H'
f'J;arne of Funernl Home (.004l' i &S e s. /-'t(ire-IZ.11C /4mg G
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 tOr 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 de[l]a(-Ids are or are not wholly groundless, false or fraudulent.
(WTNESS) (AD RESS)
;SIGNATURE 0 R L;\TIVE OR LEGAL REP. AND ADDRESS)
Sign��on this date:-
904�/g5