Ward, Theresa rl"'-,wN OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director <
Name !�pst5c, Oqr d Case# 16
Date Of Cremation Sly /6L ----t
Time Cremation Started
Time Cremation Completed
Type of Container_ Canal ylc,y,r ( .-,I jLw /
Remarks
Jo it A
AN
111160
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8
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 Rules and Regulations to cremate the remains of:
(NAME) t (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20 C
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased Sty c�
Name of Funeral Home PG AiEr'
IMPORTANT
I represent that to the best of my knowledge, the deceased has r o acemaker 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 harmless Pine View
.,rematodum 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 as directed,whether
such claims or demands are or are not wholly groundless,false or fraudulent.
MES , (ADD DRESS
cam'
(SIGNATURE OF RELATIVE OR EGAL REP.AND ADDRESS)
Signed on this date: o _
DISPOSITION OF CRCREMATEDgZMAINS dispose
of the cremated
direct Pine View Crematorium to
I hereby remains as follows:
Mail to ecify: —
Other arrangements - please sP requested, check here
If pulverization of cremate remains is
ppLICIES► RCS AM REGULATIONS
s a week '1 :00
open for cremations 5 day or Sundaysy
will be P po Holidays ements
I. The crematorium
Monday-Friday Pre-arrangements
A.M• _ 3:30 an be made for Saturday.sessary.*
arrangements acceptance of remains is
telephone for on the grounds of the Pine
Corium is locateueensbury•
2. pine View Cr eke Town of 4
Qua Road, signed by the nearest
View Cemetery, 4 they do have
for cremation properly stating that of the
3 . An authorization erson the cremation
of kin or other authorizes range for cremated remains,
next and authority toof the
disposition be
the power direct the View
remains and to less pine of
r ossessions have either been
harmved or m
any personal P rotect, defend a and demands for to
that agree to P claims connected
destroyed and ag any and all reason of i
from ainst them by disposition of said
Crematorium be made ag remains and/or or are
damages which maY of said claims or demands are,
with the cremation whether such This authorization in
remains as directed, false or fraudulent. the remains.
not wholly groundless, permit must accompany
addition to a regular burial pernate
cased in a casket or suitable lbustible
All remains must be en containers must b accepted.
4 • Caskets and will be
container. No Styrofoam or Plastic containers answered
material. pacemakers must be will be
question relative to cardiac efore the
5, The � cremate f°�
on the authorization tO sins will
accepted. cremated rem
ements are made the crema s of cremation
6. S, Mail within three dw11 be a $25.00
b Unless other arrange
tered U• There
be mailed via Reg the service.
to the f�ethishome
service cling 300.00
charge for Fee: Adult $
12 years) $150.00 Infants (stillborn
mation, Administration Coosts and Recording
Ch 13 months t
Children (age 100.00 3:00 p•M-
to 12 months) $ s will be
100.00 charge for cremationson done
3;30
* Additional $ Cremations done after
Monday through Friday. 100 .00 Any remains received
charged the additional will be charged an additional $100.00.
P.M. Mon-Fri or Saturday