Fuller, Alexander a '
TOWN OF QUEENSBURY
Pine View Cemetery ntid Cremntonum
21 Qunker Road. Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //w%v\v queensbury net
Funeral Director. k
Name of Deceased:Case Number:
Number:
Date of Cremation:
Retort: C IV�Aw U tl— J
Time Cremation Started:
Time Cremation Completed:
Type of Container: �/��y� �✓d �Z" l 3 r� �j�j+
Remarks:
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nr n / N' nttirn1 Benuty . A Cood Plnie to Lice
• 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 cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
P.M. Monday-
1. The crematorium will be open for cre na ements can be made for Saturday.0Pr arrangements
Friday. No Holidays or Sundays, arrange
by telephone for acceptance of remains is necessary.'
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authoof rized
person stating that they do have the power and authority to arrange for the cremation
possessions
remains and to direct the disposition rmay destroyed and agree to protect, defend and save
d ma es
ns, that any
have either been removed or m y
harmless Pine View Crematohem b reason oaorlconnecteddwith thedcremationoof said
which may be made against Yemands remains and /or disposition of said remains
as directelent. Thisd,
horiher s cn add t claims or a egularare,
or are not wholly groundless, false or
burial permit must accompany the remains.
aterial. No Styrofoam or plastic containers will be
4. All remains must be encased in am casket or suitable alternate container. Caskets an
containers must be of combustible
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
istered
6. Unless other arrangements are maation the cremated remains will be mailed viato the funeral home handling the servicRe.gThe e will
U.S. Mail within three days of crem
be a $20.00 charge for this service. (age e 13 months to
.Cremation, Administration
(stts anillborn bornto 12 oRecordlng Fee:nh s) $75.00 It 4�_ �'I, '
12 years) $115.00 Infants
Additional $50.00 charge for cremations done after 3: .
Cremations done on Saturdays will be charged the additional
P.M. Monday through Friday
$50.00.
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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 745-4476
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:
xl�4 -- A— 7 0!�; m
(NAME) (SEX)
i4cLbj-/-) c--\- '�J - L� �L V-, �- 1 2�
(STREET) (CITY) (STATE) (ZIP CODE)
7
who died on 2 day of J/ 20 O
at � , — Gv�'1 v — N
(PLACE) (A DRESS)
Name and address of nearest living relative or name of person authorizing cremation:
l
Relationship to deceased
t
Name of Funeral Home 0w Ul.l `
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as 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 for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
TICior demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADD S)
Signed on this date: 2Z 7e 'a S
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