Haskell, Jamie OF QUEE9�523Ur
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PINE VTEW CEMETERY AND CREMATORIUM
QUA,KFR ROAD, QUEENSBURY NEW PORK 128C4
(518) 745-4476 (518) 745-4477
_ Funeral Director������„d�f
Fame S5f
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Da t e 01 Crema t ion Z- 27- O,%
Time Cremation Started
Tame Cremation Completed
Type of Container tided
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Remarks
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alM!'l of UU68nsbury
It*Vrew Cemetery and Cr+emat on im
21 Quaker Road.Qumabtuy,New York, 12804
'ecaelery Office:(518)745-4476,Crematorium:(518)745-4477
Au#Kxt dm ID Cn m W
The undersOW raq<i0ets ere elAho bm Pim View Cmamemk m.In socordartoe vAh and subject to its Rules and Regulations to
crerrrafe the rernaYts oF. - .."-.
(Flame)
7i'� /'rl7 i2IJ r ARio
(street) .r r (City) ;(fie). RIP code)
who died on 'Z Z day of E3 20 C
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Name and aftess.of neerad relative.or rwm of person auatarizlrtg creatadon:
Iy1l4 a3 d-� /,j 64Z /:6-✓/J / D, A 7q6L7 AA,(,
(Name) T (Address)
Relationship to the deceased P-?ia C-2
Name of Funeral Home- ET (,✓ v.i/�N�
IMPORTANT:
I represent that to tha.best of lay i vx*dak the deoeasad go*or(has no)Pemnalter,defb*ator,bef6ery,�y pacK power
call,radloecdve fmptenf or) ioec.H,.e davfoe in his or her body.(CWde One)
i ceNly that 1 hmo f4 pother rind dtdhwkd m%D arrange fwtlte as Adm of"retrWk1S and to direct dW lion of the
c mntated rem"tempt, MNe SXW bW gWADmd or may be destroyed,and agree to proled,defend and
save berm e�l'ris any aM ad dams ant!derssrtde for lose or domages wftich may be made agairtm them
by of or carrrar' tlrri ejandian of acid nerrralns m 0 ecl1 idod r such Naisns or demsrbs are or are not whoity
fifte or
�.; UN7�zcs�.r2G
(S'igneaas and Address of Relatrve or Legal Rapresortfaive)
signed an this dabs 2 —
i
ufsposttion of Cremated Re -am
I hereby direct Pine View C renwlorlum to dispose of the cremated remains as follows:
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other anarrgemeros-Pleaae apacXy: w i C.t, /I Uy V l'
If mdvwWdion of are nee mnairw Is r6"09d,check twee _
RevWon:April 18,2W7 j
Policies, Rules and Reguled"
1. Pine View Crematorium is located on the owunds of Pine View Cemetery.The
cxema"OPMaMs#Aonday it QUgh FFft"m 7.V m to 3:30pm. Prior telephone
arrangemem for ft sooepWM ofrednaias am rmx*ssary.Prearrangements are
necessary for overhow or Saturday crecnadors.
2. A •Authorisation to CremaW fam signed by the nearest next of kin is necessary stating
that they do have the power and aLd"Ity m OM3%e for the a emation of the remains
and to direct the disposition of the cremated remains,#0 any personal possessions
have either been removed or may be destroyed and agree to protej,defaW and save
harmless Pine View Cemetery and Ownatorium from any and aN c lakns and demands
for loss of dernages which may be made against them by i6i66n of or connected with
the cremaotion of said remains and/ardispoaition of said Fentakis as directed,whedw
such dakm are,or are not wthoNy�,Me orftudulerrt.This authorization in
addition to a regular burial Permit must accaorrhpany the renu ins.
3. All remains must be in a casket or suitable akerr►ate corhtakW. Ceske and containers
must be of a eombusWle abate jaL No Styr km or pfeslic aortkhem wiN be accepted.
4. Any carrtac pepatpadaers.defhbriltators.battery.battery Pads,Power cell, radioactive
implM or aw loscoe defte rrhust be renhved*am the body before any remains will be
5. Cnenhatioihat beoorhhpfeftd wi0hinttir+eetworlarh8 days(72 houm)of of the
Burial Trey t Permit errhd Authorb tto h i e Forty%The ownated remains will
be mailed V6 ke* er U. 4 Mimi VM"S Of CMn *M lO ft*revel home
handling the service uNew otherarrergetnerhis are made.Them wiN be a$30.00 charge
for this service.
6. Cremation,Administration Costs and Reding Fees:
Adult
Children (age 13 month to 12 years) $MOO
infants (stillborn to 12 morift) $130.00
Overtime Cremations(Weekdays) $4MM
Saturday Cremations $480.00