Betar, Harry Jr. 70 RN OF QUEEVBU-'R,,,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��/r
Name r Case # 1,34
Dat e of Cremat i cn ' (— ( /
Time Cremation Started
Q /
Time Cremation Completed
Type of Container
Remarks :
oat
11 I/ �"-1�9 /�•Nt
TOWN OF QUEENSDURY
PINE VIEW CEMETERY 6
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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 ..
ve
(Name) (Sex)
(Street ) G}� --7 City ) / (State) ( Zip Code)
who died on ( day of 19 _
at / fib
(Place) (Address )
Name, and , address of nearest living relative or name of person
authorizing cremation :
(Name) (Address )
Re.
'fat 4i`onship to the deceased
Name 'of Funeral Home k N � �1'
IMPORTANT
sent that to the best of my knowledge, the deceased has or
has no acemaker in his or her body. (Circle One )
I' c:erti�fy` that I have the full power and •aut:horization to arrange
for th'e 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 har.mless ' Pine View Crematorium from any and all claims
and`1Vimand's{t1'for less 'or damages which may be made against them by
reason of or connected with the cremat.!an of said remains as
directed, whether such claims or demands are or are not wholly
ground1es`s;`''faIs'e or fraudulent.
( itness ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 9 ( �C1�
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 cremate 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 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 of
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
� materi1al:' No styrafoam or plastic. containers will be accepted,
.•,,�. t
S:a� The question relative to cardiac pacemakers must be answered
on`° the "authorization to cremate form before the remains will be
r ' accepte6.
6 " ' Unles`s 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 s20. 00
-.charge.•.for- this service.
Cremation, Administration Costs and Recording Fee : Adult 5105. 00
_ Chi.ld.re.n_.,,.,.,(age._ 13 months to 12 years ) $ 11;0. 00 Infants ( st i 1 1 born
to 12f months>tSa70, 00