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Oathout, Harry TOWN OF QUEEVBU9KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director IR0)0. � lL� ►� T - Name �Wf�y �c_ Case# yl-) Date Of Cremation tO �- OS Time Cremation Started t : 0c) A'm Time Cremation Completed 1;� '.©o `�eY✓1 Type of Container CCA6,," Remarks ;� C r Aw�a 15..E Ca!C ryx oL-n an 16-D D A)WI Mo ue�• � ' 3s n,.., cc) p rr, L0 TOWN OF QUEENSBURY L 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 Ru es and Regulations to cremate the remains of: (NAME) (SEX) (STR ET) CITY) (STATE) (ZIP CODE) who died on � day of C- 20 at �L CA- ( LACE) (ADDRESS) Na a and address of nearest livin relative or name of person authorizing cremation: P L ( /I - v�-e Relationship to deceased Name of Funeral Home 4 "` IMPORTANT I represent that to the best of my knowledge, the deceased has or Ocemaker 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.har i ss Pine View Crematorium from any and all claims and demands for loss or damagaes.vichaY be mad6fa against them by reason of or connected with the cremation of said ted,whdtiher;� s I ims or dema d are or are not wholl groundless, false or fra a � x (WITNES (ADDRESS) 21 (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: 6cl - . 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. Pre-arrangements 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 or damages 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 demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular curial permit must accompany the remains. { 4.t All remains must be encased in a casket or suitable alternate container. Caskets and 49 containers must bebf 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. Unless other arrangements are made the cremated remains will be mailed via Registered ?- ail within three,dj�yys of cremation to the funeral home handling the service. There will 8.00 charge fdMis service. C tiob, Ad,-nist n Costs and Recording Fee: Adult$300.00 Children (age 13 months to r _ (stillborn to 12 months) $100.00 A'd 00 charge_fpr cremations done after 3:00 P.M. Monday through Friday. Crem `rdaVs will be charged the additional $50.00.