Call, Clarence Funeral Director: 1 v%
Name of Deceased: AA-
Case Number: eZ
Date of Cremation:
Retort: -Pia1A,v--GTL-
Time Cremation Started:
Time Cremation Completed:
Type of Container: ?d tgo 14I-zj 'ALI 1 71 3
Remarks:
TI
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TOWN OF CUEENSBURY ` r
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, QueensbUry, New yort 'i
04
Phone (518) Crematorium 7 5-4477 (it nolanswer)
Cemetery 748-4478
AUTHORIZATION TO CREMATE I
The undersigned iequests and authorizes Pine View Crematorium, i f j
to its Rules and Regulations to cremate the remains of;
n accordance with anc{subject
77(NAME)
(SEX) -...,_.
Dow
{STP,EET) L (CITY) 6 k � c
(STA E} (ZIP CODE) ";-- .
Who died onc5 I
-------�=--�----y�� day of ' I
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at {PLAC�j U� 11✓I
(ADDRESS) -------x>y �
Name and address of nearest living relative or name of person authorizin cremation:
'
g matlon: I
Relationship to deceased ------------
Name of Funeral Horne
Lake Placid, NY 12946 ' -
IMPORTANT
1�
I Wresent that to the best of my knowledge, the deceased has or as acemaker in pis or I
body. (CIRCLE ONE) her
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I certify that i have the full power and authorization to arrange for the cremation of the rE,m ins and
to direct the disposition of the cremated remains, that any personal possessions have el' ..
r beenremoved or may be destroyed, and agree to protect, defend and save harmless Pine Virvir
Crematorium from any and all claims and demands for loss or damages which may be rxracfe
ag2H15t them by reason of or connected with the cremation of said remains as directed,zwftiether
such claims or demmnds are or are not wholly groundless, false or fraudulent. tj
N
iTNSS) (ADD
P,ESS}
X
(SIGNATURE OF RELA IVE OR LEGAL REP, AND ADDRESS)
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Stgned on this date: O -, 3 o Q
p ;
f
f
blSp{)SiTION of CREMATE-� REMAINS
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Pine View Crematorium to dispose of the cremated remains as follows: 'I
i hereby direct S� �
Mail to
Other arrangements-please specify:.,_,_,._.._... if
If pulverization of cremated remains is requested, check here _ , l
POLICIES,RULES AND REGULATiQNS
can be made for Saturday. rearr pg,pments
1. The
crematorn.im will be open for cremations 6d ays a week 7:00 A•M• � 3:30 p,M. �,�rtday•-
Friday, No Holidays or Sundays, arrangem
by tefet�hone for acceptance of remains is necessary
Pine View Cemetery, Qua1,56fOoad,
Pine View Crematorium is located on the grounds o .
2. P► I
Town of Queensbury.
cremation properly signed by the nearest next of kin or other al h f t ed
� .
3. An authorization forpower and authority to arrange for the crem1 tICI s scions
person stating that they da have the po rated.defend and sv!=
remains and to direct the dispasiti be destr of the yed and ag pelto� at any p
have either been removed or may and all claims and demands for ions orlanages
harmless Pine View Crematorium from any whether such claims or de. nds are,
which may
be made against therm by reason of or ronendecied with the cremation of �d
remains and for disposition of said remains as direct
re not whoily groundless, false of fraudulent, This authorization in-addition to a fleuiar
or a the remains. f
burial permit must accompany
4. Ail rer rains must be encased in a casket or suitable alternate
ce container.plastic cant ine s wil b?
containers rswst be of combustible material. No Styr {
accepted.
5. The question relative to cardiac.pacemakers must be answered on 1�authariz.atic�� io
cremate form before the rernains will be accepted. k i
6. Unless other arrangements are made the cremated remains will be mailed via Re shred
U.S. Mail within three days of cremation to the funeral home the 58N1CG, i
be a$20.00 charge for this service.Cremation, Administration Costs and Recording Fee: Adult$226,00 ChAdren(age 13 -nonths to
`
12 years) $115,00 Infants (stillborn to 12 months) $75.00
Additional $60.00 charge for cremations done after 3:00 P.M. Monday through Frioll.
Cremations done on Saturdays will be charged the additional$50,00.
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