Burnham, Dorothy '7"O r N OF QUEEN,-50uoPWE YI �
VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, Q(IEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745'.4.477
Funeral Director
Name
mate Of Cremation
— i V1
cAr�l. 1:2 �vu7
Cremation Started
� . me Cremation Completed 10
� xPe of Container 7F r _
� �5
S'
Remarks
------------
i 07
Ton of Quatnsbtay
Pir►e v w w Cemetery and Crematodurn
21 Quakor'Road,QtiIligntsbury,New York, 12804
Cemetery Of om:(518)745-4475,Crematorium:(518)745-4477
Authorization to Cremate
The unders4nw requelts and guemkos Pft view Cremator+wn,in somFoortm with and suNw e0 Its Rules end Ropai"w"ro
crer»ate trte feealne d
cot zJp
ISM) C7 (CIO (am) (Ztp 00")
who died on ._ day d—V2 20 a 7
at (PMca) (Adrrraes)
Nam*and ad""at naarsei living►Meow a nadta d parson arMrvrt"cr*n ^%
(Name) t
Rele0onWp to Ito*da0eesed h.]c ra h
name of runaml Herne ;5��o f,�r F+'.t2
IMPORTANT, ne aker,d*obtiNstor aretry orrer b�my orrer*ad
I rapneerrt put to ow beat of e�►tartmtadpa.Im dww$W thee)a l m )tom^+
device in w or her bony Pole One)
I aeniry rnrt I nave ftAt pow ww euftrt oom arenerge far to arlrrtatiat of ew m mko rind to dkW the dier�oaltfen d the
arernatad?eras m Ilret any peramw palmloM e<:hove atther rivet removed or may be dedMW.and ameeb stand
saw t+armkss Pkn VleaGlarnalarhrh tege>rfr+xpea aN dslms arrd Oerrwets tartoss or darn V—vo tth eir n et
by roesort of or oonnaotsd rM ts,e pentaeor►d*aW n>»netns as ,pdAd.*ftttw mxh Omm or demands era cr are not vrh wy
groundlses,false or*Rudurar+.
(S AOdnes ar �1
Sorted on tt�ls^tl*te /0-7 ...
DhiMition of Cremated tze004
I►rareby dived Pine Waw Crametodum to dbpow of"CrMn in Umpires m fotbra:
Mall to
ottw amonoemeeom-PAM spedry:
I!puNerixatlor=ai erenralad n:rr+alns a►rloc►allod,cftack tter*
Rcvi9ion:January i,20H
c�,ur�nccN a� t'. �t=1L J.P,It?-�=,✓I-ddlJ
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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 ules and Regulations to cremate the remains of:
( E) t t (SEX)
..JCL% � i ',L . ///r� - •^ � e /
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of fi,P.0 20Q'1_
4c
(PLACE) (ADDRESS) l'
Name and address of nearest living relative or name of person authorizing cremation:
v j A �t
Relationship to deceased
" G
Name of Funeral Home
IMPORTANT / �l
I represent that to the best of my knowledge, the deceased has has no pacemaker 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
.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 as directed,whether
such claims or demands
are or are vlly groundless,false or fraudulent.
• i � ,�,.� �� -- - 3 391a �v cd�,ecti-. kdc j u��au� �a� I
(1MTNESS) (ADDR SS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) �J Z
Signed on this date: b� �q
L
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify:
If pulverization of cremate 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. Pre-arrangements by
telephone for acceptance of remains is neuus5diy.*
2. Pine View .Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
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 of
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 $25.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $300.00
Children (age 13 months to 12 years) $150.00 Infants (stillborn
to 12 months) $100.00
* Additional $100.00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100. 00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.