LeBlanc, Pauline TOWN OF QUEENSBURY
Pine View Cemetery and Crenintorinrn
21 Qunker Road, Queenshury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
htrp-//w\v\v.qucensbury.net
Funeral Director: riay14\z-
Name of Deceased: 19 A Q L ti G
Case Number:
Date of Cremation:
Retort: 'E—' f;21 ALA-) �Q 67-C1
Time Cremation Started:
Time Cremation Completed: J I/V*V
Type of Container: 04 tZL) ✓�1ZcJ �,( r) 3 Q
Remarks:
i
i
i
" Honie of Nntitrnl 8enitty ... A Gooil Plnce to Live "
TOWN OF GUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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
cr ate the remains of:
U 1m e, JNJ ke- A �.
(Name) (Sex)
r dS o A)
(Street ) (City) ( . ate) (Zip Code)
who died on ZY4 day of sZ.
at D L S �;Du`Z4 i.e. F15? AJ-y�
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
222,d4 1 0 P-,q L
(Name) ,c ('Addres )- �
--� f♦
Relationship to the deceased nil al z� 1iL
Name of Funeral Home �^r���'^`r-1 rU7 -ea-a/
IMPORTANT:
I re that o the best of. ay ..knowledge, the vcsased hA*,,. _Qr
has no pacemaker i 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 pra%Vct, defend
and save harmless Pine View Crematorium from any T+d.."All claims
and demands for loss or damages which may be made . Iga .st them by
reason of or connected with the cremat of mans as
directed, whether such claims or demands ;;are 4r a ,t � t' lly
groundless, false or fraudulent.
_,-. .1-y. J. VOY;`� �/`+,AID
(Witness) (Address) ..-
:r York
(Signature of Relative or Legal Rep. an Address�sionftp;res�? y15, 19..15
Signed on this date : 394A \QA-A
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Z�
Mail to ?,C-
a
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. Prearrangements 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 authorized person stating that they do have
the power ,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 Crematorium from any and all claims and demands for loss of
,damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of said
`remai•ns as directed, whether such claims or demands are, or are
root wholly groundless, false or fraudulent. This authorization
in addition to a regular burial permit must accompany the
remains. '
4: ?ial"1'`'`remains must be encased in a casket or suitable alternate
cli +ain�' Caskets and containers must be of combustible
+IMeriai. . No styrafoam or plastic containers will be accepted.
5.. ° " The question relative to cardiac pacemakers must be answered
on the authorization to cremate form before the remains will be
accepted.
6• Unless other arrangements are made the cremated remains will
MAi310d' via Reghtered U. S. Mail within three days of cremation
y °_to tie funeral horde hc Tdling the service. There will be a s20. 00
vhar}ge for this ,s hvice.
6remation, Administration Costs and Recording Fee: Adult s175. 00
Children (age 13 months to 12 years) $100. 00 Infants ( stillborn
to 12 months) ,s60. 00
y