Beamish, Ann `WN OF QUEEVBU9Zy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I I ,,e(
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Name_ Ann 170(4VVI15` Case# if ( 0
Date Of Cremation Iy Iq /G S
Time Cremation Started 9 '' L4 5 A .M
Time Cremation Completed I�', 10 P tj
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TOWN OF QUEENSBURY C I I U
PINE VIEW CEMETERY
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 G 200 ,5
at LLA-e- C-Eurp.
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
�d q tiA) M J9 fiS/f
Relationship to deceased Pgv�/J?y=4
Name of Funeral Home_ // �/ Lon -e—,,-- /I-- i7
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as n pacemaker 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"-edw
removed or may be destroyed, and agree to protect. defend and save JoWlessRihe 1Aew`
Crematorium from any and all claims and demands for loss or damage may be made
against m by reason of-or connected with the cremation of said remainsJU,iirected;.wtieMer
suc la s or eman are or are not wholly groundless, false or fraudulent. ^�
( TNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: (U ` 1/C)
P
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DISPOSITION OF CREMATED REMAINS '
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to _ ��S(Yl�� ,
�Ja✓�
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 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.
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. Unless other arrangements are made the cremated remains will be mailed via Registered
l, l within three days of cremation to the funeral home handling the service. There will
' dt ,gharge for this service.
Cremiation, Administr Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants.(stillborn to 12 months) $75.00
Adcktional,$50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations one on Saturdays will be charged the additional $50.00.
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