Wickham, John I
TOWN OF QUEENSBURY
Pine Vieta Cemetery and Crematorium
11 Quaker Rond, Queensbt(ryr NY. 12804 '
(518) 745.4476 .5902
hIfPJI %v%v.queensbury.net (518)74 5.44 77
Funeral Director: ' j-
/' �iho�Gi
Name of Deceased:
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Case Number:
Date of Cremation: '� L
Retort:
e
Time Cremation Started: - 5
Z
Time Cremation Completed:
Type of Container: A rc v4 4
Remarks:
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Al
" Ho ,,, e o/ Natural 8enuly ... A Cool Plnc• e In Live "
4 2 5-6
own toy Oueanaburr
?ire View COMUMV and C maoaeoriwn
21 Quaker Road.Quwatit",New Yak 12804
'ataowy OfBoe:(518)745.4476,Crematorium:(518)745-4477
Audxxt Ww Ip C nunate
The undets%"W ad allAttortaett Pine view Ceet>gd'X'k 1, p wd subject m its Rues and RepAWk ns to
cremate the retnairls ot:'
John P. Wickham Male
( ) (Sep
_22 King Street, Warrensburg, NY 12885
(Street) (Cky) (Stara) (Zip Code)
vAvdW«e 24th ' ' drat May 20 08
at tE
( ) tAddttess>
Name and address of _ p reisthre ar rrsrne d q�a�ion
(Name) (Address)
ReWdonshtp to the deceased /1gJ6 1c
Name of Funeral"on*Alexander-baker FH, Warrensburg, NY
IMPORTANT:
I re;xeeertt that%P ttte, t f4.WV M no peamadw.daobrMallor,benery,be tery peak,power
cell,iareoactiv�e intpteint cr tsdioecdve device it his a her body.(Cirt;le One)
I cw*that I have fal power end autltorbmtlon to anenpe forte a of Qte tw ak and to Bisect the deposition of the
saw herenlws PlrlaPkls r r r wand aY.clei e11d bee ar wtich may be made against them
by reason of or t s'kallAelioin d said remaMlsais drede4 such claims a deanart in area are not whogy
Wnrrpnshurg , NY
(Address)
x717 L.(G1?12daIe 1' Same as above
(Sgrteturs and Address of Relative or legal PApmswfttive)
signed on this date: 5-2 5-0 8
Uisposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remabrs as fohows:
Mail to
Other -P . FH will pick up
If pulvertation of creffeW wriatns is requested,check two _
Revision:Apr#18,2007
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday tt augt Friday from 7:OQam to 3:30pm Prior telephone
arrangements for the acceptance of remains are necessary.Preerrangements are
necessary for overtime or Saturday cremations.
2. A 'Authorization to Cremate form signed by the nearest next of kin is necessary stating
that they do hem the power and audwity to arrange for the cremation of the remains
and to direct the disposition of the cmmated remains,#0 any personal possessions
have either been removed or may be destroyed and 99W to pFoteM defend and save
harmless Pine view Cemetery and Crematrxium from any and all claims and demands
for loss of darrmges which may be madwawkwt Mon by reason of or connected with
the cremation of said remains and/ordhposition of said remains as directed,whether
such claim are,or are not wholly gmundlem fabe tW*sudralers.This audw zation in
additian to a regular burial Permit must accompany the rs.
3. All remains must be in a casket or suitable akenw*e container. Caskets and cons
must be of a Combustible materiaL No styraloarn or plesdcconu*ws wig be accepted.
4. Arry cardiac Peca akars,delibrillalc s,baUNY,battefY Pam.Per cell, radioactive
Implant or r8dJOSC VIS device must be FOW41W*am Wo body before any remains will be
5. Cremations wi to can~within tb111" . ems)Of of the
Burial T1U11"�,Petndtertd Authotfi lwt '+ ! rM-&FblK:VW cremated r will
be malted vie A er+ed U.S.A�tsiltlitl tilr+e8 days of tMrlelin 1110 Ike funeral home
handWV the service unless other anangerrre ft are mackL There will be a$30.00 charge
for this service.
6. Cremation,Administration Costs and Reop*p Fees:
Adult
Children (ape 13 months to 12 years) $180.00
lnfa U (stillborn to 12 monft) $130.00
Overtime Cremations(Weekdays) $480.0i?
Saturday Cremations $480.00