Grossjohann, Marcus rl-ncWN OF QUEEVBUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 13 K-drnsf
Name ArCL, C—roa& 'yk"Kti Case#
Date Of Cremation
Time Cremation Started A .M
Time Cremation Completed
Type of Container ctir�( �a�c. r;�
Remarks
m ►r T AM _ rny��
Oct 05 05 04: tOp Mark Levine 519-439-0379 p. 2
11:11 5187477548 M.S. KE-MER a44,,E 2
TOWN OF QUEENr>BURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Read.Quggnst)ury New Ycyk $2804
Phone(518)Cremptoriurn 745-4477(it no answeri
COrn*161Y 745-4476
AUTHORIZATION TO CREMATE
The Unclersigneo requests and auftriZeg pine View Cremator«
lo'ts RUIes and Regulations to cremate the remains of um- in accordance with and subject
C*&WClJS,-ADMS,-G&L1"S GRossjo W
1 (NAM
(SEX)
34 SPORE ROAD D NEW YORK 12054
(STREET)M-ET) (cl
Who(lied an 3rd _day of OCTOBER 05
at GLENS PALLS 134i'IT& I?b.Ry,
(PLACE)
Nam and address of n
z 92r9st living relative or narne of person EluthOrizinq,-�rernabon:
41
Niihi'of'Funtfal Rtj Ixw-xEmmu'L
LEV
IMPORTANT''
I represent that to tho 004t
may. she SMaker In his or her
. .................��._,a.��-�.,,�...�..,�.,.a��. :.
I certify thbt I have the full power and ri'a
6 suft zatiOn to among&for the clOmBlion of the remains and TM
to direct the disposiVon of the cremated remIllims,that any peMnal possessions have either bw
reMoWd,of
CT tmpum�
or dowasivftei'msy moo
"OR Claims end demands for loss
such Claims or demands are or 0 not wholly grounolagg.*116 Of fraudulent
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&
-RELATI E LEGAL REP. AND Ikdok-tSS)
On,this date: 4 J,
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W, c oN el **)4c ini;firtih,"k 1;1k�Maflvnof h
XQkv�.n, ilefend p0d,$ave"- irmt 4�", j*W
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
w� wcxskinctbon Ave
Other arrangements-please specify:
If u►venzati
p f 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 010ueensbury.
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
U.S. Mail within three days of cremation to the funeral home handling the service. There will
be a $20.00 charge for this service.
Cre iqn, Adroinistratlbn Costs and Recording Fee: Adutt$225.00 Children (age 13 months to
12 years) $118;00 Infants*(stillborn to 12 months) $75.00
' Addifiortel $50.00 charge for-cremations done after 3:00 P.M. Monday through Friday.
Crarrgitions-dog, on Saturdays will be charged the additional $50.00.