Metz, Mary . y
70WN OF QUEEN
,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � mt(I
Name 0.CMatz Case#
Date Of Cremation Io / h /05'
Time Cremation Started 1 = 3y A M
Time Cremation Completed (0, 60 .�
Type of Container Ctir4 St <<,,x I F. E_
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
r
' 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 sudject
to its Rules and Regulations to cremate the remains of:
iac e\ e�-Z—
(NAMfo (SEX)
wcscen�
2< < sn y 81(27
(STREET) (CITY) NJ (STATE) (ZIP CODE)
who died one{ day of 2 2005
at �-GkP <3eoc�F N`(
(PLACE) (ADDRESS) `
Name and address of nearest living relative or name of person authorizing cremation:
S'F
Relationship to deceased U S\301A
Name of Funeral Homo . 1<N rmes (w CG' "C mle
IMPORTANT
I represent that to the best of my knowledge, the deceased has orbas no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cre. rVWI s and
to direct the disposition of the cremated remains, that any personal f s l e#t1*been
removed or may be destroyed, and agree to protect. defend and s�ve ss fte me .w "
Crematorium from any and all claims and demands for loss or dart ges y'l melds
against them by reason of or connected with the cremation of said remain ;whether
such claims or demands are or are not wholly groundless, false or fraudutet '` ' r
(WITNESS) (ADDRESS) �.
�:
(SIGNATURE OF RELATIVE OR LEG L REP. AND A R - )
Signed on this date:_ '�
DISPOSITION OF CREMATED REMAINS
I hereby directPine View Crematorium to dis(p�os-e� of the cremated
cremated remains as follows:
Mail to _l rPM(� C�l� SG C\e G �S1�w\ 1 r\C
[ S 2- :5 1
Other arrangements-please specify:
If pulvenzatioA 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 property 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
burial permit must accompany the remains.
a 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 rAnains will be accepted.
y
6. Unless other err gements.are made the cremated remains will be mailed via Registered
U.S: M'aii wiihin t ays 6f cremation to the funeral home handling the service. There will
be-a.$2Q,0'0 char this service.
Cremation, Am mWelion Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years)`$1 1?4 t nts (stillborn to 12 months) $75.00
Additional Sft= chaNe for cremations done after 3:00 P.M. Monday through Friday.
Cremation$4horr, lays will1be charged the additional $50.00.