Fiorino, Rose r7�O ti�N OF-:. QUEENSB
PINE VIEW CEMETERY AND CREMATORIUM
QUA M ROAD, QUEHNsBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
tiame
oSQ hoe .no Case a 50�
Date of Cremation I 3 ZC)oC
Time Cremation Started
Time Cremation Completed_ 3' 1;
T y P e of Container CI���, - /- Ifvw�
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name)
(Stare) (Zip Cale)
(Street) (CKY) I
day of / .3�� 20�
who died on
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address) 77/
Relationship to the deceased
Name of Funeral Home
I
IMPORTANT: the deceased(has) taC rw�y►
tiv Peer,deflbriliator,battery,battery pack,Power
Ow I represent to the best of my Wwwledge, rR4i;0
cell,radioactive implant or device In his or her body.(C no)
I Certify that I have full power and authorization to arrange for the cremation of the remains and to direct the ed,and agree disposition
of the
end and
cremated remains,that any personal possessions have either been removed o may be destroy Proms
save harmless Pine View Crematorium from any and all claims and demands fo loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are riot wholly
groundless,false or fraudulent.
(witness) — Address
�� 4 , 4�t7
(Signature and Add r of Relative orLegal Representsfive)
Signed on this date:
�y �9 ADD
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: 'I LL trP .
If pulverization of cremated remains is requested,check here !/
Revision:January 1,2W9
Policies, Rules and Regulations
hone
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for overtime or Saturday cremations.
2• A "Authorization to Cremate"form signed by the nearest next of kin is necessary
that they do have the power and authority to arrange for the cremation of the re
and to direct the disposition of the cremated remains that an stating
have either been removed or may mains
and to ProtY Personal fend a lions
harmless Pine View Cemetery and Crematorium from any and all�i defend and save
ms an
for toss of damages which may be made against them by reason of or connectteed ands
the cremation of said remains and/or disposition of said remains as directed with
such claims are, or are not wholly groundless, false or fraudulent. This authorization e n
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate container. Caskets and con
must be of a combustible material. Nos rofoam or plastic containers will be tamers
� p accepted.
4• Any cardiac pacemakers, defibrillators, battery, battery implant or radioactive device must be remov from the body before anwer ly remains' �will I be
5. Cremations will be completed within three working days (72 hours) of receipt of the
. The cremated remains will
Burial Transmit Permit and Authorization to Cremate Form be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be f$30. I charge
for this service, g
6. Cremation,Administration Costs an
Adult $350.00
Children (age 13 months to 12 years)
Infants (stillborn to 12 months) $150.00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations $550.00
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11;'b2'�bb� l�f: i b'_�tl�.�l4b :- PLANERAt. HU E" PAGE _11
i�lN1!'�bt?M �Q:59 '318459i1��J ..i.LStRa
5TATZ OF dBRlt NT
EXAMINER'S MrCHtTTO CREMATE A DEAD HUMAN BODY
Felt Hama of dedt lit Rose M. Fiorino
t e
34 Abare Road Whitehall New York 12887
Docedant'a addrear
Damotticath _1 1 /2 8/0 9 _ _ p6c., of 11vatl+ Rutland Vermont _
Cauthe of daalb certified Ly Sudden Cardiac Death
port1116fioll to cremate 111c bulky of 111is decedent at -- --
Pine View Crematorium Queensbury New York
(Kruk and a,tdrv..1d Crvo,atar;) - —
Itt• l►cen rcqucrtcc!It Jay T. Jillson
Vcrtuoul F. O. NY 01786 46 Williams Street Whitehall NY 12887
Mucuee Nu. —{t+l•lw•r.f�t.,rr.rt t):Pr.'!YP)
fltIng ruUI,:IUfliir infwrnruJ An to tltt cauicf and tlrevHWaIlLes or the �colh of t+ze ijLovc
d�-ya�ri_bt,.J- JZur4ucc:.jter+aicr.i0n iY ilc.•rCLy�ratlicaf to crGcr+Ald t�1Q boJy at;rCt(t+C�tri1.
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