Decker, Richard Jr. TOWN OF QUEENSBURY
Pine View Cemetery rind Crematorium
27 Qunker Road, Queenshury, NY. 72804.5902
(518) 74 5.44 76 (518) 745•4477
http://www.queensbury.ne(
Funeral Director: CAI
Name of Deceased: C�'J� -`'`. '� �C- K e--F— YL 1--?,
Case Number: 3 sue)
Date of Cremation:
Retort: IA LtJ ) f7.-
Time Cremation Started: Z.,
Time Cremation Completed: 2
Type of Container:(2TnJA-�
Remarks:
" Home o/ Notural Benuty ... A Good Plnce to Live "
TOWN OF QUEENSBURY (
PINE VIEW CEMETERY
&
CREMATORIUM
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Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
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AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Dine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of: ;, •_
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{NAME} _(SEX) Sam .,r"�...!..�.......
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(STREET)� (CITY) (STAB) (ZIP CODE)
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who died on day of �� I) OQ
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(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Carom Decker 41 Oveltette Circle, Kees_e--ville,. _NY_12C
Relationship to deceased
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Name of Funeral Home 1A__1-
IMPORTANT
I represent that to the best of my knowledge, the deceased has o a�o acemaker inbi�or her
� s
body. (CIRCLE ONE) (j
I certify that i have the full power and authorization to arrange for t r remation of the r m ins and
to direct the disposition of the cremated remains, that any personal ssessions have eliher been
removed or may be destroyed, and agree to protect, defend and saA harmless Pine Viev,G
Crematorium from any and all claims and demands for loss or damages which may be qla;de
against them by reason of or connected with the cremation of said remains as directed,sw(lether
such claims or demands are or are not wholly groundless, false or fraudulent.
_ - 1IL (�- I—Z.—�— Q-»S '� �r.—A�r•�-. r• Take P 1 a C 1 rl r NY
(WITNESS) (ADD RE S)
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C1- (`l�g�.41 Ovellette Crl .Keeseville, Xt 944
(SIGNATURE OF RELATIVE OR LEGAL REP, AND ADDRESS)
Signed on this date:
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DISPOSiTION OF CREMATED REMAINS
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I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to d C',�lFi /✓� d I
Other arrangements-please specify.-
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
r:
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. lJp1 iday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday, Prearrahgbments
by telephone for acceptance of remains is necessary."
2. Fine View Crematorium is located on the grounds of the Pine View Cemetery, Quak r Road,
Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other ad hr rized
person stating that they do have the power and authority to arrange for the crematrrsn bf the
remains and to direct the disposition of the cremated remains, that any personal p ' s ssions
have either been removed or may be destroyed and agree to protect, defend and s< vie
harmless Pine View Crematorium from any and all claims and demands for loss or ,a&rages
which may be made against them by reason of or connected with the cremation of lid
remains and /or disposition of said remains as directed, whether such claims or deer_ids are,
or are not wholly ,groundless, false or fraudulent, This authorization in addition to a h-epular
burial permit must accompany the remains.
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A. All remains must be encased in a casket or suitable alternate container. Caskets aid;
containers must be of combustible material. No Styrofoam or plastic containers will'bP
accepted.
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5, The question relative to cardiac pacemakers must be answered on the authorizati4i. t'o
cremate form before the remains will be accepted. i
6. Unless other rrangements are made the cremated remains will be mailed via Reg sw,red
1,13, Mail wltfflh three days of cremation to the funeral home handling the service, ,rjilere will
he a $20.00 charge for this service. j
Cremation, Administration Costs and Recording Fee: Adult$226,00 Children(age 131ronths to
12 years) $115,00 Infants (stillborn to 12 months) $75,00
` Additional $50.00 oharge for cremations done after 3.00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.
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