Rehm, Phillip TOWN OF Q UEENS B UR Y
Pine Viety Cemetery and Cremntortnm
21 Qtrnker Rond, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp iiw%v%v queensbury net
Funeral Director: L 9d
Name of Deceased: PV\,`� , 1Ta� /&
Case Number: l
Date of Cremation:
Retort: e p,, 14
Time Cremation Started:
Time Cremation Completed:
Type of Container: n ; �' ✓Irl t4-�' ► - D 1��
Remarks:
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1-21L-4
" Howe of Nnturnl Benuty ... A Conti Plnt: e to Ltue
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as fol;ows.
""Ian to
Other arrangements-please specify
lr Pulver zation of creri�ated rer'nains is requested, cheO here
POLICIES, RULES AND REGULATIONS
The crematorium will be open for cremations 5 days a week 7 00 A.M. -, 3,30 P.M Monday-
Fiid�iv No Holidays or Sunday,&, arrangements can be made for Saturday. Prearrangements
r,y telephone for acceptance of remains is necessary.
Pine Vir w Crematoriur-n is located on the grounds Wthe Pine View Cemetery, Quaker Road,
own of OL, eensbury
fin authorization ror cremation properly signed by the nearest next of kin or other authorized
person stating that they do have the power and authority to arrange for the cremation of the
remains and to ci ect the disposition of the cremated remains, that any personal possessions
Vhave either.then removed or may ber destroyed and agree to protect, defend and save
IVA& Pine View Crematorium from-any and all claims and demands for loss or damages
w rch may be made against them by reason of or connected with the cremation of said
rema [is and /or disposition of said remains as directed, whether such claims or demands are,
or are not wholiy groundless, false or fraudulent This authorization in addition to a regular
burial per
mit mit trrt accompany,the remains.
0
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l All remains must be encased in a casket or suitable alternate container. Caskets and
acceptted ers must be of combustible material. No Styrofoam or plastic containers will be
acce
The q_resticn relative to cardiac pacemakers must be answered on the authorization to
cremate torm before the remains will be accepted.
Unless other arrangements are made the cremated remains will be marled via Registered
U S. Marl within three days of cremation to the funeral home handling the service. There will
be a $20.00 charge for this service
Cremat on, Aamrnrstration Costs and Recording Fee: Adult $225.00 Children (age 13 months to
12 years) $115,00 Infants (stillborn to 12 months) $75.00
Additional $50.00 charge for cremations done after 3.00 P M. Monday through Friday.
Cremauons done on Saturdays will be charged the additional $50.00.
TOWN OF QUEENSBURY l
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 ana Regulations to cremate the remains of:
PAi%//`Ap -7.7 "1*4e
(NAME) (SE
(STREET) (CITY) (STATE) ( IP CODE)
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who died on day of �,pl�✓ L 20Q�
at S �. 4
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
.-„v..s .vw
Relationship to deceased (.50 h
Name of Funeral Home V i I1SOh t7"v '74-1C.
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
r
1 certify that I have the full power and authorization to arrange for the cremation of the remains and t
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 t
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)
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;SIGNATURE OF RELATIVE OR LEGAL REP, AND ADDRESS)
qZ)Signed on this date: lw j