O'Connell, Bernice S
TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Qunker Road, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //w\v\v.quecnsbury net
Funeral Director:
Name of Deceased: .8CfZ N z L 5, I-o J us e-Case Number: f
Date of Cremation: .3 3 0
Retort: T- E
Time Cremation Started: ')
Time Cremation Completed:
Type of Container: Cl L4 �Z� ���/ ./Vl t.l - 6 ►4
Remarks:
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" Ho e of Nntitrnl 8enut A Goo ,1 PInre to Live "
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of Lhe
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 io 5 daysays or w ek7 : 00
A.M. - 3:30 P.M. Monday-Friday. Pre-arranyements by
arrangements car: be made for Saturday.
telephone for acceptance of remains is necessary.
2. Pine View Crematorium
is To loco Queensthe grounds of the L'l Hie
View Cemetery, Quake Road,
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the po
wer 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 are
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 Styrafoam or plastic containers will be accepted.
ust be
5. The questioh relative crematediac form beforeers the I remains will rbe
on the authorization to
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U.S. Mail within three days ofecre$atio00
to the funeral home handling the service. There will b
charge for this service.
Cremation, Administrati
on Costs and Recording Fee: Adult $300. 00
Children (age 13 months to 12 years) $150.00 Infants (stillborll
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
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charged the addit}onal $100.00 Any remains received after 3: 30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(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.
Bernice Louise O'Connell Female
(NAME) (SEX)
96 The Portage, Ticonderoga, New York 12883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 28th day of February 20 05
at Moses-Ludington Nursing Home, Wicker St. , Ticonderoga, NY 12883
(PLACE) (ADDRESS)
Name and address of nearest Hying relative or name of person authorizing cremation:
Phyllis Steele, 96 The Portage, Ticonderoga, New York 12883
Relationship to deceased Daughter
Name of Funeral Home Wilcox & Regan funeral home, 11 Algonkin St. ,
Ticonderoga, New York
IMPORTANT
I represent that to the best of my knowledge, the deceased has or hgam pacemaker in his or her
body. (CIRCLE ONE)
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 prated,defend and save harmless Pine View
Crematorium 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)
(SIG TURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: