Haskell, Charles TO,MN OF QUEEVBUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
f�jryarrl e
Name 1,C' S I��ti�G U
Case#
Date Of Cremation —ob
Time Cremation Started
Time Cremation Completed , Z%3p QM
Type of Container r� sh� t
Remarks
ti
ru=
Ati
q: 4S11l
oSOH
Town of Queensbury
Pine Mew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4478, Crematorium: (518)745-447-1
Authorization to Cremate
The undersigned requests and author¢es Pine View Crematorium.in accordance with and
cremate the remains subject to its Rules and Regulations to
Charles E. Haskell Male
(Name) (Sex}
21 Mountian Rd. , Athol , NY 12810
(Street) (City) (state) (Zip co*
who died on 21 s t
clay of-., . September 20_0.fi
at Glens Falls Hospital , Glens Falls, Ny
T ) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
( } (Address)
Relationship to the deceased
Nameof Funeral Horrte- Alexander-Baker F hneral Hama Tnr
IMPORTANT.
device in Wesent that to the best or her Of MY �,the deceased �(has no)pacemaker,defitxillator or any other battery operated
body. (Cade One)
I certify that f have U power and authorizaftn to 8AMW for the cremation of Qte teams and to direct the disposition of the
cremated 7. 2orwiththe
any pal Possessions have either been rernoved or may be destroyed,and agree to Protect,defend and
save harmCrematorium firm any and all claims and demands for loss or damages which may be made against them
by cremation ofsaid r+enwhis as directed,whether such claims or demands are or are?not wholiy
Warrensbur , NY
) (A )
(1 Legal Represernative)
Signed on this date:
Disposition of Cremated Remains
hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: R t n t me
If pulverization of cremated remains is requested,check here
Revision:January 1,2t)U6
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:008m to 3.30 arrangements for the acceptance of remains are necessary. pm. Prior telephone
necessary for Saturday cremations. Prearrangements are
2. A Authorization for Cremation"signed by the nearest next of kin is necessary
that they do have the power and authority to arrangefor the Ming
and to direct the dispositiox of the cremation°f remains
have either been removed or d ,that any Pal possessions
defend and ve
harmless Pine View Cemetery and Crematorium#rcxnman�y acid aWed and to�j maims and demandssa
for loss of damages which may be made against them
the cremation of said remains and/or d' � of or connected with
such claims are,or are not wholly �sposition of said mains as directed, whether
addition to a regular burial if g�nd�'false or fraudulent This authorization in
permit must accompany the remains.
3. All remains must be in a casket or suitable aitemate
must be of a combustible material. No contamer•Caskets and containers
styrofoa+n or plastic containers will 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 p�k and Authorization mate FF days(72 tx5} receipttere of the
be mailed via Registered U. S.Mail within three days �cremated to the
remains will
handling the service unless other aura y cremation to the funeral home
for this service. its are made:There will'be a$30.IX?charge
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12, s) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 00