Stice, Darlene OF QUEE9�(s50U_W�
PLNE VIEW CEMETERY AND CR
EMATORTUM
QUAKER ROAD,
QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745-4477
Funeral Director L
D Cased
ate Of Cremation 3_�g-_Og-
Time Cremation Started ,K� ,rn
Tame Cremation Completed Y� is �
Type of Container C6/11 [?oc4r
cL s7, CgSe
Remarks
0 _
Move-
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urlpr►of O wwoblw
Ins View Cemelwv and Crematorkrn
21 Choker Road. ,NowYwK 12804
-'MOM Ol oe:(518)745-4476,Crematorium:(518)745-4477
Audxxlza *n to Cremate
The wWWSWW requeek tartct lffew ccelat ,h >wirf►�ltxt Bract a tis Rees end Repuleaions to
�rY(LG C- 57�CC- �cIVA
(Name) (S)
OWP) Op Code)
who died on dsy of /1'Lo&W ZO��
at C;LCGU.S ub'' /763-P ow—_
(Place) (Ad*ess)
Name and address.d rte"fivt roledws or name of person ndwrb tg orerrtwt m
14-)UA Il mess 9 ccocv
(Name) T— (Address) '
ReiadonsW to the deceased
Name of Funeral toms_4 L �C.t oce
T
IMPORTANT:
I represent that to On bast of my kowwdge,the deoeaged(has)or pins no)pacenroker.defrvator,battery,baftery Pam,Poww
cell,radioactive implant or radfoactire deride in his or her body(Circle One)
I certify that 1 have U power w d atdwri sOm w arrarW far tf to peroration of the ratriakts end to&W the melon of the
cxesrrated. 4 . .:, s o
m lO+raldorowbodmoDyad,end aWea topnclo w defend and
save Pins fnogt arty and at derkatbM� bsr dt# pas which may be made agehtst them
of or oort eranr�on dseid rarrNintttlle v er such cr demands are or are root whovy
proixxiiess,false or .. _ .
( ) (Address)
A&i\/-?, -1`,,,, 4 S 04 .i, A-4 - 322i -/717-C
MLA
and of Relebwa a t egaiNfaeap�e lire 07- 2
v ML1 V4vAk_ss y
Signed on this date: 3-
U"osibw of Cremated Rernakis
hereby d'W Pine View Cremal wkm to dispose of the cremated remains as follows:
Mail to
Ottiet aRarlQernentS-PIBaaB Spadry: f'�'r�<J!GL /-t C(� (//�
If puhretf�tlon of ansrrwoad rarosins is rer�.+sctsd,check t►vre,�_
Revisor:Apr»18,2W7
Polkies, Rules and Regulations
1. Pine View Crematontum is located on the grounds of Pine View Cemetery.The
crematorium opt Monday dwotgh Friday from 7:00am to 3:30pm. Prior telephone
arrangements forthe acceptance atr+emakis era necessary.Prearrangements are
necessary for onrert me or Sattuday cremadom
2. A 'AutlIIorbMfion to CremaW form signed by the neared next of kin is necessary stating
that they do have the power and atdalty 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,deRW and save
hamdess for toss off Cemetery Cey and Crematorium from any and all c l&ns and demands
damages which may be n>nde a then!by reason of or conneded with
the cxemadon of said remains and/or disposition of said as directed,whether
such claimare,or are not wholly gi�aurt�iless,raise ar'*SUWert.This authorization in
addition to a regular turfsd permit must accompany the remains.
I All remains must be in a cashes or sty allernefe contakw. Caskets and conwkws
must be of a combuMUe material.No sryc*M cr PWMC MUIrMMwill be wed.
4. Any cwdbc Paoerpakera.deftbrilta>t M battery,bed/per.power cell, radioactive
fmplW or redioace.device must be renwieed*orn the body before any remains will be
accepted.
5. Cremations rrilfr be eomptetad wd*w*00 wanking days(72 hours)of receipt of ttce
t ,11 r11 Sm AudKwbs m'Ib Cart W H'OOL The cry mated vAD
be trsa�edf d R**ftW U.s. M8N' t' t"ftS of et+emedon ID the ften i home
handling the service t other anwnAemerrts are made.There wdl be a$30.00 charge
for this service.
6. Cremation,Administration Costs and $ 1D330' Fees:
Adult
LWIcIren (age 13 months to 12 years) $180.00
Wants (stilabonn to 12 months) $130.00
Overtime�(Weekdays)
Saturday $480.00