Dyslin, Margery Z- r-?
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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CREMA l'ORILIM
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Quaker Road, QueensbUTY, New York 12804
Phone(518) Crematorium 745-4477 (if no answer)
Cemetery 7�5-4476
AUTHORIZATION TO CREMATE
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The undersigned requests and authorizes Pine View Crematoriurn, in accordance with a d I subject
to its Rules and Regulations, to cremate the remains of:
J�Z-v
(NAME) (SEX)
-J-4y /,I V
(STREET) (CITY) (SArAYE-T7 (ZIP CODE
who died oil day of 2 1 U
L',r I-A 1044e-112 A.1V -9
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home —C-4�4
II
IMPORTANT
I represent that,to the best of my knowledge, the deceased has or krLs 7557>cemaker in, is (.,)r her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the rr:�rrMins and
to direct the,disposition of the cremated remains, that any personal possessions have e1i &r been
removed or may be destroyed, and agree to protect, defend and save harmless Pill jtj�
Crematorium from any and all claims and demands for loss or damages which may be crude
against them by reason of or connected with the cremation of said remains as directed,'Wtij ether
such clairns or dernands are or are not wholly groundless, false or fraudulent.
WETNESS)
GN
ESS
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(A E.4 SS)
SrGN J )F RE OR L. -3AI READ ADDRESS) w51 'I
igned ont sdae:
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A
rrO raN OF QUEEVBUP�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , \ !3
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Name L k Case#
Date Of Cremation 2
Time Cremation Started 2) co �� ✓��
Time Cremation Completed ' 3 Q 1✓ Z�
Type of Container�lL}\?-� �7j(j 2f� i1/I �d.L 1�7A j
Remarks
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DISPOSITION OF CREMATED REMAINS
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i hereby direct/mine VieW CrernatoriLIM to dispose of the cremated remains as follows; li
Mail to
Other arrangements-please s erA
if pulverizatlon of cremated remains is requested, check here !
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POLICiE-S, RULES ANF) RF„GULATION$
1. The Crertnaloriuin will be operr tr3, cre j)atic,ns 5 clays a week 7,00 A V1, - 3:30 P,M. IMpriday.
Friday, No Holtdays or Sundays, arrangements can be made for Satul,day, C'rQBrras�c�emcanl;;s
by telephone for acceptaicp of remains is necessary.`' f
2, Fine View C:reriiatoriLim is located can the grounds of the Pine View Cemetery, Oual r lRoad,
Town of Queensbriry.
3. An authorization for creration properly signed by the nearest next of kin or other at)it
person stating that they do have the power and authority to arrange for the crern 'Irlrt bf the
remains and to direct the disposition of the cremated remains, that any personal pcdssicrn�
have either been removed or may be destroyed and agree to prolect, defend and Sr vri
harmtess P111B View Crematorium from any and ail claims and demands for loss Or blarirrage
which may be made against there by reason of or connected with the cremation of ad
remains and /Qr disposition of said 1,e17tains as directed, whether such claims or de hr.nds are
or are not wholly groundless, false or fraudulent. This authorization in'Addition to a War
burial permit must accompany the remains. r
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4. All remains must be encased in a casket or suitable alternate container. Caskets Ad!7
containers n-tust use of combustible malerial No 13tyrofoarn car plastic containers wil 1)
accepter.
5, The question relative to carrdiae pacemakers must be answered on the suthorizafill do
crernatc form before the remains will t)e accepted. I
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6. Unless other arrangements are made the cremated remains will lie mailed via Re st�red
U,7, Mail wits}in three days of crernatjon to the funeral hol-ne.handling the service, l"r'i`ore will
be a $20.00 oharge for this service.
Cremation, Adminlstratlan Costs and Recording Fee: Adult$225,00 Children (age 131ilkipnth�; to
12 years) $115,00 infants (stillborn to 12 171onths) $75,00 i
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Additional $50 00 charge for cremalions done after 3.00 p M. Monday through Frida y.
Cremations done on Saturdays will I)e charged the ardditionaf $6(}.DO. F
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