Fitzgerald, Elsie z
(7-oTIN of QUEEN5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-A ex,;, W,-
1 I
Name e � z �(al�l Case # gg
Date of Cremation Plc-'A� lr d , 200
Time Cremation Started - � ' Ip Ain
Time Cremation Completed (U. 15Ali
Type of Container ��� G�✓cal CV F0R F"r) f—n'c
Remarks :
t lD
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Offtee:518-745-4476,Crematorium:518-74.5-4477
Audwrization to Cremate
The undetstgned requests and s0w0tws Fine t/iaaw CmmAW fum,in aocwdsaoe vdth and subject to Its Rules and Regulations to
cremate the remains or
Elsie M. Fitzgerald Female
(Name) (Sex)
24 Orton Drive , Warrensburg, NY 12885
(Street) (Cay) (Slime) (Mp Code)
who died on 17th dsyot December Z09
at 24 Orton Dr . , Warrensburg, NY 12885
(Place) Vkddress)
Name and address of nearest living reiaiive or ream of person a=wrmng crematim
East Stroudsburg, PA 18302
(Name) (Address)
Relationship to the deceased daughter
Name otF-uneraiHome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemelm,deftftlaW or any otttelr beftery operated
device in his or her body- (Circle One)
I certify that I have full power and art WdZEMW to WMngS for the crernatim of the remains and to direct the disposition of the
cremated r+emakm that any personal po orts how ei:tter been removed or er r be desUvied;lord agree to proteM defend and
save harmless Pine View Creamaxium born arty and ali dams and demands for foss or damages vtdch maybe aaade age them
by reason of connected with Vpcmvw1km of sold m 2weirs as dsec1ed,vAntiersuch tJhr4 or OR, Fv ds are or are not iotbolty
ground"ess Lqe
If ft
W"/ ;Z� 3&�
(Witness) a (Address)
(Signature and Address of Rekme or )
5igneooninlsdate: December 18 , 2009
Di,Sposttfon of(:remateo Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as toilows:
Mail to
Other arrangements-Please specify: F H will pick up
If pulverization of cremated remains is requested,checK teem x
Revision:4wy�-,�dd4
Policies, Rules and Regulatiom
1. Pine View Crematorium is bated an the grounds of Pine View eery. The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"s!gned by the nearest next of kin is necessary stating
that they do have the power and auth�s{y to a for�Q�of�mains
and to direct the disposition of the cremated remains,that any personal pions
have either been removed or may be destroyed and agree to protect, defend and save
harmless Pine View Cemetery and Corium from any and all claims and demands
for loss of damages which may be made against them by reason of or connected with
the cremation of said remains andlor disposition of said remains as directed,whether
such claims are, or are not wholly 0nxffxvess,false or fraudul nt IWM authorbation in
addition to a regular burial permit must any the
3. All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material- No styrofoam or plastic containers will be accepted.
4. Cardiac paeemakas, defibrillators or other baftery operated devices must be removed
before any remains will be asxepted_
6. Cremations will be cmyq eted wid-An three worldN day3(72 )of apt of the
Burial Transmit Permit and Authorization to Cremate Form.The mated remains will
be mailed via Registered U. S.Mad w hin three days of cremation to the funeral home
handling the service unless other arrangements are made.There wilt be a$?fi;00 charge
for this service.
6. Cremation, Administration Costs and Recorcling Fees.
Adult S38Bj' -3i�. -"
Children (age 13 months to 12 years) SISO..W f go-
Infants (stillborn to 12 months)
vrt2��;�c VDGW_ 4301