Galusha, Estella OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l{�Q,�g,��s�
Name tSt 4, 41U0 Case# 35�
Date Of Cremation
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Time Cremation Started � ; ;to
Time Cremation Completed (. ?')
Type of Container CSr4�jUgr� Cr� GrCO lSi CASI-
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned rests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Estella Galusha Female
(Nam) (Sex)
Johnsburg, NY 12843
(Street) 5th (City) (State) (Zip Code)
who died on day of Aug• 2006
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
ceoiz r:g ICtwWM PO Box 16 Z" A]
(Na ) (Address)
Relationship to the deceased
Name of Funeral Home Alexan er-Baker FH Warrensburg, NY
IMPORTANT:
I represent that to the Crest of my larowledge,the deceased(VgK)U(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
i certify that I have full power and aultiorbxifion 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 Trine View Crematorium from any and aN claims and demands for loss or damages which may be made against them
by reason of or con cr em aid remains as directed,whether such claims or demands are or are not wholly
groundless,false raudulen
�'Warrensburg, NY
(Witness) (Address)
(Signature dth Address of R taWie or Legal Representative)
Signed on this date: 8—5-0 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: F H will pick up
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
Policies, Rules and Regulations
1. Pine View Crematorium is looted on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. p��ngemerrts are
necessary for Saturday cremations.
2. A 'Authorization for Cremation'signed by the nearest next of kin is necessa
that they do have the power and authoriting
ty to arrange for the cremation of the remains
and to direct the disposition of the cremated remains,that any Personal have either been removed or may be destroyed and agree to protect,defend and save
harmless Pixie View Cemetery and Cmmatoriurn from any and all claims and demands
for loss of damages which may be made against them by reason of l wed with
the Cremation of said remains arx!/or disposition of said remains as directed.Sher,
such claims are, or are not wholly groundless, false or
addition to a regular burial firaudulwlt- This authorization in
permit must accompany the remains.
3. All remains must be in a casket or suitable alternate container.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers s be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three
Burial Transmit permit and J�iuthori working days(72 hours)of receipt of Cremate the
be mailed via Registered U. S. Mail within three daysof the cremated remains will
handling the services unless other atrart cremation to the funeral home
for this service, are -ire will be a$30.00 charge
&. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12.,nonths) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 00