Hughes, Caroline rrn%N OF
PINE VIEW CEMETERY AND AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M 9
Name ��6V 1� ucs- Case#
Date Of Cremation f0 2Time Cremation Started M
Time Cremation Completed L4 tj Aa
Type of Container C \Z!✓' C}���✓ /Y► .\y �� SC� �? /f�,
Remarks
� 2 t\
i
i
i
TOWN OF QUEENSBURY '
PINE VIEW CEMETERY tl
& '
CREMATORIUM j I
I
r'
I
Quaker Road, Queensbury, New York 12804
Phone(518) CrernatoriUrn 745-4477 (if no answer) n
Cemetery 745.A476
AUTHORIZATION TO CREMATE
I f
The undersigned requests and authorizes IDine View (crematorium, in accordan c(subject
ce with a'n
to its Rules and Regulations to cremate the remains of'.
(NAME) (SEX)
(STREET) (ZIP CODE)
who died an day of(PLACE
at D/ wDA /c � /tom i •' I
) (AbDRESS)
Name and address of nearest living relative or name of person authorize }on: g
Relationship to deceased ,----�'
Name of Funeral Horne /c�?, 12 , du/Z 1AIC .
i
IMPORTANT
I represent that to the hest of ray knowledge, the deceased;bas remakar in i,,t or her
body. (CIRCLE ONE)
I certify that i have the full power and authorization to arrangB ematioi ofrthe rf ins and .
to direct the disposition of the cremated remains, that any *ions have a #r r been
removed or may be destroyed, and agree to protect, dqzf#i° unless Fine Vip?
Crematorium from any and all clairr►s and demands for Ios rru4ich may be t.;tfe
against them by reason of or connected with the crematio ns n directed, Tether
such clairns or dernands are or are not wholly groundless, lent:
( TNi SS) (ADDRESS)
(SrGNATIJRF C)F R TIVIw LEGAL E CP/�f
Signed on this date:� (�',
w> tk r
A
k � ri
i
fit
WSPOSITION OF CREMAI'ED REMAINS
it f
I hereby direct Pine View Crematorium to dispose of the cremated remains as follow.,z., "I
Mail to
7
Other arrangements-Please specify-
-i7 If pulvetatlon of cremated remains is requested, chec,k here
- , ULF�S AND RFGtJLATION$
POUCIF SR
1. The, crerriatorium will be open for cremations 5 days a week TOD AN, - 3:30 RMI Jpridav
Friday, No Holidays or Sundays, arrangements can be made for Saturday. Prearr pry)'ents
by telephone, for accepiance of remains is necessary.*
5
2. View Crel)iatorium is located on the grounds of the Pine View Cemetery, owak r;load,
Que'e T f nsbory.
C
up'3. ization for cremation properly signed by the nearest next of kin or other rad1horized
Ig 'i lj ,
P ting that they do have the power authority to arrange for the crernatiLfri bf the
re d to direct the disposition of the cremated remains, that any persona!
�c k
elt hay. e elt been removed or may be, destroyed and agree to protect, defend and s vl.i
harm' less 'e View Crematorium fron) any and all claims and demAnds for loss or lilaUlage-s
m
which rn made against theiii by reason of or connacted with the cremation of'46i4d
remains or disposition cif said rernains as directed, whether such claims or dem'_ rlds are
Or aF& r*t Wh011y groundless, false or fraudulent, This authotizalion in'addiflon to a' ular
burial permit must accompany the remains.
4.4 A1.1 rem* be encased in a casket of suitatfle aftmrnate container-, Cas U
kets a).'id,�
140" "1 Containers' stbe of cornbUShb-le maleriai No ,Styrofoam or plastic contalners, W11,11 1)��
accepted.� 7�
5, The questl#Ysistive to cardiac pacemakers must be answered on the authorizafloi' fo
-crenate forrn;beforp the remains will bp ancer�'od,
fl J
6. Unless other arra e#neTits are made the cremated remains will be mailed via Reg slbred
I
U'S. Mail wit t
'If 1111,11181ion to the funeral hornp,handling the service, qrj'i,ere will
be a$20.00 service.
Cremation, Adi '13 n6nths to
;is and Recording Fee: Adult$225,00 Children (age
12 years) $11 'tillborn to 12 months) $75,00
rZ
5
Additional ,-qPwalions done after 3.00 P.M. Monday through Frida"
Cremations dor., be Charged the additional $60,1)0,
' if
io