TenEyck, Bradley i
3.
TOWN OF QU'EENSBUR Pins Virtu Cemetery and Crematorium Y
21 Quaker Road, Queenshury, NY. 12804.5902
(518) 745.4476
htrp://www.queensbury.ne( (518) 745.4477
Funeral Director: /t�t " .o
Name of Deceased:
T F G.
Case Number: Z3`
Date of Cremation: (�� Z 3
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Retort: �w
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Time Cremation Started: I y 1
Time Cremation Completed,: ' Ph
Type of Container: N 00
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Remarks:
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The ttfid 111tftftn f kw V%W GtemwAM4 in, x v th ird subject to its Rules and Regulations to
cxemme the retrttiii�Ok<'
Bradley C. TenEyck Male
(Nam) (sft)
20 LaFond Way, Olmstedville , NY 12857
(SLreet) (Cky) (state) (ZIP Code)
„WtodW«t 16th dwof May 20 08
at Glens Falls -:Hos .
(Mace) (/address)
Name and address of nearest*AV relative or name of person a 4mizlnp cremation:
Karen Ten Eyck, Same .as above
(NMO) ( )
Relationship to the deceased . S p o u s e
NameotFtxmWFbms- ' Alexander FH, Inc. , North River, NY
IMPORTANT:
c mi rafoeom knpteiyt orb� ��q��)Paoe+naloer;daf>br�ator,ttelte►Y, efY Pam,power
I certify that I tom fuw power aid augmilmOm w ttr wig for ttm aEt make Gf the masks end to duect the disposkion of the
c renmftd rertz+al m t hm~bM ralWmd ar mW be dsmtayeck and agree to protect,defend and
save hermles8 t?kts from am and 410 chftka tend dernartds for toes or demopas vh*;h may be n►ede agar tst them
by reason of wCammmom Mter such daiats or demands are or are not wholly
false or
Warrensburg, NY
(Address)
Same- as above
(Soma is and Address of ebum or Legal Rep e9w tetive)
signed on this date: 5—18—0 8
Disposition of Cremmed Remains
I hereby direct Pine View Cremm d m to dispose of the cxemeted remains as fok ws:.
Mail to
oww arrangements-Please spew. F H will pick up
If pulverization of ournated remains Is requested,check here X
Revision:April 18,2D07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
cxerrhat iutn operMs Monday thr+oh�h Frklt r*am 7:00am to 3:30pm. Prior telephone
arrangements frxthe eooepl5arice�r+ i one necessary.Preanangenenm are
necessary for overtime or Shy cremations`
2. A 'Authorization to Crhamate'form signed by the nearest next of kin is necessary stating
that they do have the Power and BtiY to age for the cremation of the remains
and to direct the disposition of the a nftd temps,thM arhy personal possessions
have either bean removed or may be dOOMWed and 89M 10 PlotJect,defend and save
haffniess f Pine View Cemetery and from any and all calms and demands
a 1 by c+enson of or wed with
such daifis are,acre not ��ssid �as directed,urttether
addition to a w..... er*�.This auOxxt anon in
regular burial permit must accompany the rarnains.
I AN retrains must be in a casket or suitable atleirna a c'ornalner. Caskets and cortairhers
must be of a oorrtbU%Me magi.NO Styra0oa n or Pf, gic containers win be accepted.
4. Any cardiac pavernak�ers,defhbriltators„ Y POCK Power cell, radioactive
implant or radioacd"device must be removed tbm the body before any remains will be
5. Cmmaftm,iwill b a nhpleted within ft*&worMnhg days Q2 host")of recelpt of the
Burial Tmn"*.pm*and AiANxba
be OM* Me f`o�.The cremated remains will
trhailed vie Rieg E3r+sd rfr U.S. MalMdlhitltit "ftsOfct+lMMIJron 1000lerrte M home
f�! he hservice c arrmpenre NO are made.Thera wN be a$30.00 derge
is se .
6. Cremation,Administration costs andR90Mp .
Adult
C;hikkw (ape 13 months to 12 years) $JSMW
Wants (stilioarn to 12 months) $130.00
Overtime COOMefts Saturday Cremations (Weekdays) $408.0�
$480.00