Gradwell, Theodore r.ti "(WN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_��QX�„���G
Name - u Case# q0 )
Date Of Cremation ` 130 /0s
Time Cremation Started PQ v �M
Time Cremation Completed
Type of Container Wood C4
Remarks
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PINE VIEW CEMETERY
. &
CREMATORiuM
Quaker Road. Queensbury. New York 12804
Phone (518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
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:
T �
(NAME) 44"
S� lei, I? (sEx)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on �S os— �S da E of 7.
y 20 0-9
at
(PLACE) /(ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Al,4 A)(I V Jie 7bls 1V lely
Relationship to deceased_ `
!F q
Name of Funeral Nome � G�iF '
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no body. (CIRCLE ONE) pacemaker in his'or her
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 eithei 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 th on of or connected with the cremation of said remains as directed,whether
such rn demands are or are not wholly groundless, false or fraudulent.
�L
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: 9- 2,&--off
DISPOSITION OF CREMATED REMAINS e
I herebv direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: K& /D
If pulverization of cremated remains is requested, check here _
POLICIES, RULES AND REGULATIONS
I, Tip crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M. Monday-
F . No Holidays or Sundays, arrangements can be made for Saturday. Pre-arrangements
by t&phone for acceptance of remains is necessary.`
,1
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Qoeensbury.
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 ind to direct the disposition of the cremated remains, that any personal possessions
hava e' b6on removed or may be destroyed and agree to protect. defend and save
haffrdess PWICrematorium from any and all claims and demands for loss or damages
which m oyf be against them by reason of or connected with the cremation of said
remains and/O&isposifion of said remains as directed, whether such claims or demands are,
or are notwh ndless, false or fraudulent. This authorization in addition to a regular
buft'permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam 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. Unles ipther arrangements are made the cremated remains will be mailed via Registered
U.S.Mail within three days of cremation to the funeral home handling the service. There will
be a$25.00 charge for this service.
Cremation.Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $150.00 Infants(stillborn to 12 months)$100.00
* Additional$50.00 change br�remations done after 3:00 P.M. Monday through Friday.
Cremations done on Satu�d ;will be charged the additional$50.00.