Pockette, Lee <� TOWN OF QUEENSBURY
Pule View Cemetery nod Cremnlortum
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 74S•4476 (5 I8) 74S•4477
htrp iiw\v\v queensbury net
Funeral Director: �.� -�'.� "5Z
Name of Deceased: To-H IJ
Case Number: 1 C6 b
Date of Cremation: - �- 0
Retort: I
Time Cremation Started:
Time Cremation Completed:
Type of Container: C'4`70t77
Remarks:
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
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; 5 days a Week 7:00
A.M. - 3:30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Pre*arrangements by
telephone for acceptance of remains is necessary.
2. Pine View Crematorium s located on
Queensthe grounds of the Pine
View Cemetery, Quake ,
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the powpr 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
Crgg�nnotorium from any and all claims and demands for loss of
da nalel
iicb may be made against them by reason of or connected
VOIZcremation of said remains and/or disposition of said
remains as directed, whether such claims or demands are, or are
not wholly g a dless, false or regular burial permit mustnaccompany. This athe o rization in
addition to a remains.
4. All rremaki us ,Must be encased in a casket or suitable alternate
cont,tai er. Caskets and containers must be of combustible
A 406 ' ayrofoam or plastic containers will be accepted.
5. The question relative to cardiac
form before the must e remains will rbe
ed
on the authorization to cremate
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U.S. Mail within three days of cremation
to the funeral home handling the service. There will be a $25.00
charge for'fthis service.
Cremation, Administration Costs and Recording Fee: Adult $300.00
Children (age 13 months to 12 years) $150.00 Infants (stillborn
o 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
� charged .the additional $�00 00 An remains receive after ill be charged an additional $100 003.30
P.M. Mon-Fri or Saturday
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
L e� -TOAA -Pnc_YN 4 I
(NAME) t t (SEX)
(STRE (CITY) (STATE) (ZIP CODE)
who died on Qalnft day of J9 0 T 20—a'�'
at -s-- kLt ,' Q �-C)<1 Hvs� f"2/ -r r W.Y
(PLACE) (ADDRESS) 1 a 8�3
Name and address of nearest living relative or name of person authorizing cremation:
Al U 1 Po to ff i ® 9 (A .+ .St , .-Ti c_onderi ga,
Relationship to deceased
Name of Funeral Home ) /C U / ,� di .
/1/
IMPORTANT
I represent that to the best of my knowledge,the deceasqrd has 4r 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
matorium 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)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: