Winslow, Joan TOWN OF Q UEENS B UR Y
Pine View Cemetery nnrl Crrwnfnnum
21 Qunker Roa(s, Q,eenshury, NY. 12804.5902
(518) 74 5.44 76 (518) 745.4477
htrp r/W%vNv queensbury net
Funeral Director: lv*v
Name of Deceased:
Case Number: 3
Date of Cremation:
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Retort: 1 CE
Time Cremation Started: -, " Z6; L4
Time Cremation Completed: t
Type of Container: C(A\2D VoA
Remarks:
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TOWN OF QUEENSBURY
M PINE VIEW CEMETERY
8
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 and Regulations to cremate the remains of: `
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20 U
at—
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home /171 13 �—
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no acemaker in 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 protect. defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of connected with the cremation of said remains as directed, whether
such,clairps or demands r or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
4
DISPOSITION OF CREMATED REMAINS ,
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverization of cremated 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 :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 or.dayle$es
which may be made against them by reason of or connected with the cremation of said
remains and /or disposition of said remains as directed,whether such claims or de
eta area;
or are not wholly groundless, false or fraudulent. This authorization in addition,to. ire r�
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Cas'kets�#a'' ' "' ,'.
containers must be of combustible material. No Styrofoam or plastic container`sWdi`tse"'�
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization toi
cremate form before the remains will be accepted.
6. Unless other arrangements are made the cremated remains will be mailed.,via..Rggistered,- .
U.S. Mail within three days of cremation to the funeral home handling the,seryice, ,There Wj l
be a $20.00 charge for this service.
Cremation, Administration 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.
Cremations done on Saturdays will be charged the additional$50.00.