Bruno, Betty 1'iltr Vic.:w C.:�n�el:e ry 8t C.;rc iri�tl.c)rtUlTl
QuilkU Road
(, UCCI bury, NY 12HOia•
74,5A477 car (•)18) 74.5-/1476
rd
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- ..._.-..__.................._Case No. �3 g
Date OfCrenrttion__-�II51Iy Still tcd-_Il iS'M •I'inte Cornl>Icrccl. ..
Placed in I-Iold: ---
Placed in ReFI-igeratiott:
Placed in
Type ol•Cont'i Ilcr
Remarks
Main
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Place of Dcall t
[stimal.ed Wcighl. ()I• Rcnmins and Container---_ -- -
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Date&'Time Rcittitins al I ived al.C;relltat.orY_._ . I
Name of rune roll Dircct.ot' or RcgisCcrcd Rcsicicnl. [)c;liverilll; iZcllt,Ii,,, (err `r
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DebLiled reason for delay it rcnrtins were e;rcntalecl ntrn'c (ltln 11.8 l om, Irort) time of;tecel>ted
delivery
Retort Nunlbu in which Remains were crcin,tl�el Sc (� /�
Nole:'I'lle Crerltillion I,oK shall Itc rct;tinccl in (lie l'crlttanenl. I'ilc Uf lllc C rCnt,Uory ------
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days aweeh--,--00'R:M. --3`30-rMAvlonday-
Friday. No Holidays or Sundays, arrangoments can be made for Saturday. Pre-arrangements
by telephone for acceptance of remains is necessary."
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
person stating that they do have the power and authority 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, defend and save
harmless Pine View Crematorium from any and all claims and demands for loss or damages
which may be made against them by reason of or connected with the cremation of said
remains and/or disposition of said remains as directed, whether such claims or demands are,
or are not wholly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
6. Unless other arrangements are made the cremated remains will be mailed via Registered
U.S. Mail within three days of cremation to the funeral home handling the service. There will
be a $25.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $150.00 Infants (stillborn to 12 months) $100.00
Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
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:
�G� JYiJn7 0 ��m oa
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of "� 20_-
at G l Q'r UV'c�-tr� (
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
)" — n'
kf
Relationship to deceased w� =--
Name of Funeral Home - ` U ve i-!0 d ,�
IMPORTANT
XI represent that to the best of my knowledge, the deceased has or as no acemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization 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, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
suqP claims or demands arp or are not wholly groundless, false or fraudulent.
is r7 ��
5��(WlTNESS) (ADDRESS) i
- 3��3
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: III - ; 4. 3