Belden, Rita TOWN OF QUEENSBURY
Pine View Cemetery and Cremn tort utit
21 Qttnker Rond, Queenshttry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http//w,,v%v queensbury net
Funeral Director: ," I,t- S QLy
Name of Deceased: -� T ��`�l IA
-
Name Number: 7 45
Date of Cremation: 3
Retort: P
Time Cremation started:
Time Cremation Completed:
Type of Container: CAA-'ry 06A-\2-d
Remarks:
O -�
A-A
" Horne o/ NntitrnI Benitty ... A 6 0 0 d P I n c e to Ltue "
DISPOSITION OF CREMATED REMAINS
tichy duect PmN `,'iew Crematorium to dispose of the cremated remains as follows
------------
C?(nel a!r 3rlgtn eats {_ie,:rsE speclry
::auon . f ren atz,i rernalns Is requested, check here
POLICIES, RULES AND REGULATIONS
fliN crenritont.ini wnll be open for cremations 5 clays a week 7 00 A.M - 3.30 P.M Mond
;Wlday� arrangements can be made for Saturday. Prearran ements
u� tale h ay-
p one rc,r acceptant=e of renialns Is necessary. 9
I'_ne View �Ir�In g(o!Iunl Is loc
0( ated on the grounds of the Pine View Cemetery, Quaker�';r�nsLury
Road,
<i_nh i=at;,�n rol cr�nr3non p!operly signed by lire nearest next of kin or other authorized
er'c;n staunil fra( they clo nave the power and authority to arrange for the cremation of
ilalns and to c:Irect the cllsposltlon of the cremated remains, that any personal osse
!'ave eltlrr�� � _, the
het n rr!nor-ed of may be destroyed and agree to protect, defend and psave scions
fIIC Hess I_ rile C;rematol lum from any and all claims and demands for loss or damn es
nick I! a ! c igaunsi them by reason of or connected with the cremation of said
y nacl � ` 9
ef't`a rl' `=inCl i'it disposition of said remains as directed, whether such claims or demands are
or arr nc t whol y Woundless, talse or fraudulent. This authorization in addition to a regular
_urie,l permit must dccolnpany the temains
~J lerri., ns must t_,e encased in a casket or sultable alternate container Caskets and
:, rfa ner , nuSt he Of combi.istible rnatenal No Styrofoan or plastic containers will be
]CCcpfCCl
e y-Iesti ,n !eiatl e fo :ardlac pacemakers must be answered on the authorization t0
mate town DEfor2 the remains will be accepted.
Uniess u(her calfangcnnents are made the cremated remains will be mailed via Registered
U S fvlail vnlhln three days of cremation to the funeral home handling the service, There g stered
0 00 charge for this service e will
�:rern�:t�on, �;urnlnistratlor� �;osts and Recording Fee: Adult $225.00 Children
years) 115 00 Inf,arits (stillborn to -I') months) $75 00 (age 13 months to
.',�Ic!ifional $50 00 charge for crernatlons done after 3.00 P.M
Monday
`re111atior�s` cone on Salurciays will be charged the additional $50 00 through Friday
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York '12804
Phone (5 18) Or 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The unc.lersigne0 reytiests and authorizes Pine View Crematorium, in accordance with and subject
to its Rr_iles ana Regulations to cremate the remains of
(NAME) (SEX)
ISM RCL-T) (CITY) (STATE) ZIP CODE)
Who died on
/' --- day of 20 Q 5�
(PLACE) (ADDR SS)
Name and address of nearest living relative or name of person authorizing cremation:
RelatiorIsnip to deceased &,e�
Name of Funeral Home
IMPORTANT
represent that to the best or ply knowledge, the deceased has or has no pacemaker in his or her
body rr IRCLE ONE)
certify that I have the full power and authorization to arrange for the cremation of the remains and
ro direct the disposition of the cremated remains, that an
personalhave
emoved or may be destroyed, and agree to protect, defend and savpe harmless Pine Viewer been
Cref`natOrlUm trom 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 c101r7Is or demands are or are nat wholly groundless, false or fraudulent,
O/VI( l- T (ADDRESS)
i ' S GNATIJRE 0 RELATIVE OR LEGAL REP. AND ADDRESS)
Signed un this date: 3 /3/0