Spencer, Barbara Pine View Cemetery 8, Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
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RETURN TIME:
DATE & TIME
REMAINS ARRIVED ......_...._..._......-_. _.
AI• CRL.MAIORY:
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NAME OF FUNERAL _ .. �f I3/ZO
ERAI. Dlfz
C FOR On riEGRISTERED RESIDENT _ -- ..__. - " . _.
DELIVERING REMAINS;
NAME: . ....._.._......_
._._....-.LASE rr i(i3 TYPE OF CONTAINER:
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PLA _ Ci(i J..
.........
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OF REMAINS W
EIGH"r !i _ . _-____
ESTIMATED
CONTAINER f
PLACED IN L7b Lbw
PLACED
115-
IN REFRIGERATION;
DATE OF CREMATION:
..............
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TIME STARTED: ( _-.----------•—
...............
LtsTtl TIME --..
PLACED IN RETofz.r: 6D --......-.._.-- ._.__.__ . . .... - .
MOVED:
RETORT JJ IN WHICH REMAINS WERE CItLMA'rED. �'I5� 2r3��f ' .__.
DETAILED REASON FOR DELAY __ _- _ .._SV�IC
IF REMAINS WERE CREMATED
FROM TIME OF ACCEPTED DELIVERY: MORE THAN 4t3 HOURS
NO ... ........
TE: THE crtEMnTION
LOG SHALL III RETAINED IN 7Ht PERMANENT rlLE Or THE CrtEMATprlY•
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TOWN OF QUEENSBURY 41113
PINE VIEW CEMETERY
' .4
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:
2R&ARP A • S '&Js�2 F
(NAME) (SEX)
5-3 w' 2c-Ns,3u. tiY (ems`
(STREET) (CITY) (STATE) (ZIP CODE)
who died on l J 76/ day of Oc 7c 12 20 Zt.)
at 6 Q ) ALL4. AJ0/2-7'i ceec4f
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
PAZgAgA A c/c iZ 263--A166C
Relationship to deceased I-t62SeLF
Name of Funeral Home /ir, —44 KL 2 �c-/l L; p ,- ,c,(`
IMPORTANT
I represent that to the best of my knowledge, the deceased h- or ha : emaker 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 b ason of or connected with the,cremation of said remains as directed, whether
such clai r ema re o arenot wholly groundless, false or fraudulent.
1 rw
(WI ESS) (ADDRESS)
(SIGNATURE OF RELA E OR LEGAL REP. AND ADDRESS)
Signed on this date: 7/'V0�p
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dose of the cremated remains as follows:
Mail to
Other arrangements-please specify: f fi' tee t.- Pr Cl✓t o JP
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. No Holidays or.Sundays, arrangements can be made for Saturday. Prearrangements
by telephone for acceptance of remains is necessary.'`
2. Pine View Crematorium is located on the grounds of:he Pine View Cemetery, Quaker Road,
Town of Queensbury.
3. An authorization for cremation properly signed by thy nearest next of kin or other authorized
person stating that they do have the power and aut' ority to arrange for the cremation of the
remains and to direct the disposition of the cremate i remains, that any personal possessions
have either_been removed or may be destroyed an iagree 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 :onnected with the cremation of said
remains and/or disposition of said remains as dir<:cted, whether such claims or demands are,
or are not wholly groundless, false or fraudulent. 'his 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 daysof cremation to the funeral home handling the service. There will
be a $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to 12 months) $75.00
* 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.