Perkins, Victoria r""'nrNN OF QUEEN,5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
or
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Fame Vic+vro po('Kin Funeral Direct
Case#. 3�(,
Date Of Cremation S
Time Cremation Started
Time Cremation Completed
2 � �
Type of Container 64rc��64r
ZA) C
Remarks
M T 2 l0 1't1
Move (z-SORI
No P
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37�
TOM of Queensbury
21 Quaker ,�, W2804
COY tom:(518)745.4476,C4 ettraWdmw(518)745-4477
Authors ID Cie
The andetsigrtedWROMad author M tW orKt m8ccwdancevftWWVJbjBdtDfts Rubs and R to
cremate dhe remains of
Name) (Sac)
2 a 2ZA1 ce�r / r3
( ) ( ►) '� (smote) (ro code)
+rFho d ad an 2 day cam-;P 2► 0,
at r GmS r t,s 14ocP�Tift_
(Race) (Atfdress)
Name and address of nearest tfe relative or rams of parsmh ahrt;xwtw g cma,wr,_
Su 1.1 r� �.- A T/Z n��7.',Gtrrl,,,�'►'1�i�c 2c:1
(Address)
Re{ omeMplothadeceesed a4UCK,,7ra2_
Name of Forest Notre t't LC-X4'-VG 2 h 14 , t-v t M A,-4
IMPORTANT_
Ito the best of my iorowkKo-,"d�sd(�or(m no)Rio.fir. Y. PwK.pmw
C811- Dot or racPoactiva device In this or her body-(Cede tine)
I oettlly that 1 how*a paver tfthd MAWft9*M tD artWW fortM CWWMM OtOMFORM&M and to(Ifred the dq)oskion of the
.r' .t Pia hM O bM or'MW be deed.and agree to WOMC.defend SW
save barn VIM Curie fhiam atW M d all c & hs and ttmds>atrr toss ttr WA(dh Uy be trade agfahst fftem big conrdKW irh COLM Lion o#sdM rer> ho as oecbed,vdmd es such ch6m or donwds are or Nor"vft*
folse,or
� ) {Address)
{ and Address of Remus or LeW m)
Signed on this date: '7 - it -J7
Of cxemated Remains
I hereby deed Pk*Vww Crenmftdm to dsposaof tha cmmeWd remains as follows:
Merit to
Ovw a mneaments-P mwe elf wr&L (1P
If PuWerUskn Of cmrroW r+er v*w is rimed,cthook hem.
RevWm:Apd18.2U07
Po ivies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematonum operates Monday dwough FrKlay from 7:00arrt to 3:30prn. Prior telephone
arrangements for the accepffince of remains are nary.Pgeanangerr>ards are
necessary for overtime or Safuc+daay cremations.
2. A "Auww z son to Cra.T a e-loun signed by the nearest next of kin is necessary stetting
that they do have the power and auft*to arrange for the cremation of the remains
and to direct the disposkion of the cremated remains,that&Y persona poss-ssi-
have either been removed or maybe desk and agme to protect,delarxi and save
harmless Pine View Cry and glum*=any and all c Wms and demands
for loss of camaiges which may be madeaWkist Won by mason of or corls*x�ed widi
the cremation of said resins andlor dts ton of s *J semaim as directed,whether
such claims are,or are not war groundleas,ftbe or iiraudtfieM This autharzatk>n in
addition to a regular burint peffnit nUM accompany the remmain&
3. All remains must be in a casket or slide akenuft ems. Caskets and comers
must be of a am s' u e meMarial,M sin or phnxic ends will be accepted.
4. Any cardiac .data,balIery.bMery ice,power cell, radioactive
implant or radioacme.devios anAa be removed*oat the body before any remains will be
accepted-
5. Crerciations wig be axn#leled w0m*me ww1ung days(72 hours)of receipt of the
EkEW Transmit Permit and ALd KNEafti ID Cie Ftum.The aid remains will
be mailed via Rego U.S. Mal alft tt+ee dM of amnabon to the kn ra l home
handling the service unfew c aria nudIa.Time wB be a$30.W ChWge
for this service.
0. GreMatlon,AOninMatM CoStS aM RecordV Fes:
Adult $330.p0
(Niaren (age 13 month to 12 yam) $18MOO
Infants (stiliboim to 12 ram) $130.W
Overtime Crembons(Wbekdays) $48D.00
Saturday cremations $ }-tic