Mason, Roger OF QUEEVBU,0�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name h :c r h
Case#
Date Of Cremation
Time Cremation Started A
Time Cremation Completed 60
Type of Container cx^��Y4'itc�� � .�� �� � 5T- Cj�
Remarks
T«J
A-(
i c; 4 f'�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)74.5-4475, Crematorium: (518)745-447 7
Authorization to Cremate
The undersigned requests and audxxwas truce View Crematorium,in accordance with and
cremate the remains of: subject to its Rules and Regulations to
f f1Tmo) (Sex)
(street) (City) (State)
!�'��" {Zip Code}
who died on -- day of A"f�Q / 20
at �l f3 / �� fTF.1/Y.c � Yusp'Vs6u.✓y
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address) ,--- •
Relationship to the deceased CA,ld 1�/
Name of Funeral Home Ab;kM.,&
IMPORTANT:
I represent that to the hest of my Miawtedge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorbztjW to ana"M for the cremation of the remains and to direct ripe of the
crematedlessremains,that any p p �have either been nNnoved or may be ,and agree to protect,defend and
save harmless t�ine� um firm any and aN claims and demands for loss or damages which may be made against them
by reason of or new wi maT+ori of said remains as directed,whether such claims or demands are or are wholly
groundless, or
Hess}
r �
twe and Address of R iveW Legs{Representative)
Signed on this date_ p �9
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arangements-Please specify: iefiy 7D /7�FI'�JiufllK r �y
If pulverization of cremated remains is requested,check here
Revision:January 1,20M
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
Crematorium operates Monday through Friday from 7:00am to 3.30
arrangements for the acceptance of remains are pngm. Prior telephone
spry.
necessary for Saturday cremations. 'Prearrangements are
2. A "Authorization for Cremation"signed b the n�
that they do have the y next of kin is necessary stating
Power and auttmrity to arrange for the cremation of the remains
and to direct the disposition of the cry maim,
have either been removed or may be t any Aossessions
harmless Pine View Cemetery and Crematoriumand agree
any to Protect,defend and save
for toss of damages which may be made any and all darns and demands
the cremation of said remains and/or d' against there by reason of or connected with
such claims are,or are not vvrioll �of��n�tins�directed,
whether
addition to a regular burial t u groundless.fade h fraudulent. authorization in
Permit must accompany�,��_
3. All remains must be in a casket or suitable alternateper.Casketsmust be of a combustible material. No styrofoam or plastic and containers
Plastic containers wilt be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must before any remains will be accepted. be removed
5. Cremations wilt be completed within three
Burial Transmit Permit and ��� )of t of the
be mailed via Registered U.�v,��Cremate Form.The
cremated
remains will
handlingthe arehree a cremation to the funeral home
service unless other arrangements are made:There vritt be.a$30.00 charge
for this service.
6. Cremation,Administration Costs and Record' Fees:
Adult �
$325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12;snorlos) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 0o