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Bisignano, Fern C:) --A TOWN OF QUEENSBURY Pine View Cemetery and Cremn tort itM 21 Quaker Road, Queensbury, NY. 12804.5902 (518) 745.4476 (518) 745.4477 http //w%v\v.queensbury net Funeral Director: r�=4 n- v Name of Deceased: 13 +S 2 I�' YV y Case Number: 11 3 Date of Cremation: l'J 1 �� Z-061 S� Retort: 'C \ fi Time Cremation Started: A A/I Time Cremation Completed: ti A'/� Type of Container: 6,9,4 i �'-Uut'1-} Gym� - NL AI 1� - 18 Remarks: i " Home of NntitrnI Benut A Good PInie to Live " DISPOSITION OF CREMATED REMAINS I hereby ereb direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to / 'Other arrangements - please specify: check here If pulverization,.of ,.cremate remains is requested, POLICIES, RULES AND REEDLATIONS r cremations 5 days a week 7:00 1. The crematorium will' be open for No Holidays or Sundays, A.M. - 3:30 P.M. Monday- pre-arrangements by arrangements "•acce tan ea of remains de for tis necessary.* telephone" for iP rounds of the Pine 2. Pine View .Crematoria Town° of Queensburycated on the 9 View Cemetery, Quaker Roa , . ro erly signed by the nearest 3. An. authorization for cremation raon stating that they do have next of kin or other authorized range for the cremation of the the power and-"authoritythe remains and to direct the disposition o been removed dor mays e r personal possessions h that any P to protect,,.defend and' save harmless Pine View destroyed and agree, and all claims and demands for loss of Crematorium from any ainst them by reason of or connected damages which may be made ' against disposition of said or demands are, or are with the cremation °whether such nclai.ms/or disP authorization in. remains as directed, an the remains. not wholly :.groundless, false permit mustnaccoIanyis au addition to a regular b MP must be of combustible 11'• remains...must be encased in ers casket or suitable alternate 4' A Caskets and contain ted. container. rofoam or plastic containers will be acc. material. 1. No Sty 5 The •`question 'relative to cardiac pacemakers the must remains will answered 5. the authorization to 'cremate form before accepted._ . '- other' 'arrangements are made the hreemdays of cremation g, Unlesated remains will s istered' U.S. Mail within be mailed vialRhome handling the service• There will be a $25.00 to the fune charge for 'this service., . . RordFee: Adult $300.00 Cremation, Administration Costs ears)e $15 1 ng 0 Infants (stillborn Children (age 13 months to ' 12 y to 12 months) $100.00 nal' $100.00 charge for cremations eon° Saturdaysne after 3will be Cremations* Additio don Monday through Friday. remains received after 3:30 charged the additional $100 be charged an additional $100.00. P.M. Mon-Fri or Saturday W I � TOWN OF QUEENSBURY ?�- PINE VIEW CEMETERY 8 CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745-4477(if no answer) Cemetery 74544.76 . 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: F- ►� t�6 1 1� I l G NAND TemAux (NAME) <, t t (SEX) . Ir � © Rt O (STREET) (C (S E) (ZIP CODE) who died on day of ='Im��RL�1 20 OS at LL-. 0 RA.KV, 5'f US (PLACE) (ADDRESS) Name and address of nearest hiving relative or name of person authorizing cremation: $ LLS,� 1 ago 1 Relationship to deceased��N Name of Funeral Homed P7 IMPORTANT I represent that to the best of my knowledge, the deceased has o bAs no cemaker in his or her body.'(CIRCLE ONE) 1 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 )ifrematorium 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 clai r demands are or are not wholly groundless,false or fraudulent. R. S s try �3 ESS) (ADDRESS) (SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) Signed on this date: