Chase, Mary TOWN OF QUEENSBURY
Pine View Cemetery nnrl Crenlntorlllnl
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 74 5.44 76 (518) 745.4477
http://www.queensbury.net
Funeral Director: /� ►'V G ��' ��
Name of Deceased: NL 11'� \2 y) '4`� C�`� �✓
Case Number: �G 3
Date of Cremation:
Retort:
T
Time Cremation Started: 1 ;L 2-O
Time Cremation Completed:
Type of Container: t \,E<: A4 F4"k/ _ I Z
Remarks:
<1 C�root� I� Awe
" Houle of Nntnrnt Beauty ... A Goott PInce to Live "
TOWN OF OUEENSBURY
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Quaker Road, Queen5bi.lry, New York 12804
CREMATORIUM
� Phone (5l8) Crematorium 745-4477 (if no
* answer)
17he undersigned requests and aL11J10r'i7_eS [-�ine View Crematorium, in accordance wit d r subject
to its Rules arid Regulations to cremate the remains of
AUTHORIZATION-TO CREMATE
(STREET) (STATE) (ZIP CODE)
who died on —day of
at AqgW
Name,and address of nearest living relative or name of person alithorizing cremation:
Relationship to deceased—
mi
Name of Funeral Haire
IMPOITTANT
I represent that to the best of my knowledge, the deceased has o cemaker in, x her
is c
body. (CIRCLE ONE)
I cerfify that I have the full power and authorization to arrange for the cremarion of the rd bins and
to direct the.disposition of the cremated remains, that any persQnal possessions have ei -�r been
removed or rnay be destroyed, and agree to protect, defend and save harmless Pine We
Crematorium from any and all clairris and demands for loss or damages which may be r-p;Eide
against them by reason of or connected with the cremation of said remains as directed,IW6,jether
such claims or dernands are Dt'are not wholly groundless, false or fraudulent.
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DISPOSITION OF CREMATED REMAINS
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here-by_ direct 1 '— '_,' _~.~..~"."'u."v"sev. the cremated remains as follow.,,;Mail to
^
If pulverizatlon of cremated remains is requested, check here--t
Friday. No Holldayq of Sundays, arrangements can be rnade for Saturday, Prearr-,al giarnents
by telephone for acceptance of rernains is necessary.*
Pine View Crp,�)iatorium is jooatecl on the grounds of the Pine View Cemetery, Quak r',,"Road,
all
3. An aulhorizalion for cremation propedy signed by the nearest next of kin or other ni'lihorized
pe�rson stating that they do have the power and authority to arrange for the Grernaticir'l I 6f thf:,-
remains and to direct the disposifion of the cremated remains, that any pargonaill 9111-iclf)s
have either been removed or rnay be destroyed and agree to protect. defend and s, vO
harmlesS Pille View Crernatorium fron) any and all claims and demands for los's or laf,"I'lages
which may be made against them bY reason of of'coil nncted with the cremation of� ,
8VIds are,
remains and /or disposition of said 1,en)ains as directed, whether sUch claims or dethr.
burial nermll must accompany the remains.
4. All remains must be encased in a casket or suit,91-1,le alternate container'. Caskets a I,
accepted
' _ The question relative to ,..,.,, pacemakers must be answered oil the authorizatio
creniato _form before -the —,_... will. ~. accepted.
Unless
' 66— will- -- .__. ,~ .`e
U,S- Mail Within three days of(.,,rernation to the (unaral horne handling the s6rvice,'
TH'Ore will
be A $20,00 charge for this service.
Cremation, Admin)BOW.1on Costs and Recording Fee: Adult$225,00 Children (age 131biontfw; to
Additional $60,00 oharg(-� 1`01-crernalions done after- '11:00 P.M. Monday through Frld@,',
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