Kelly, Charles TM� OF QUEE9�5BUT,,y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUF_ENSBUp
,y. NEW YORK 12804
(518) 745-4476 (518) 745-4477
I f ,/ Funeral Director_ (-/"K
Name C�1grl�s KP11 -
Case# 3
Date 0 f Cremation r _ )o
Time Cremation Started
Time Cremation Completed 16 ;6
Type of Container �� ��, a
WOOlEE psi ��Sr
Remarks
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Town of Queersbuty
Fine 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:
CHARLES E. KELLY MALE
(Sex)
AC IIR.N---S TREE T T..A K F .P_LA-C.IIl4--IY_
(st�) (City) (State) (Zip Code)
who died on — - #� _..�—�^ day of ] ECEM$.ER_--. .zQQ6._.
at _ ADRK MEDICAL .CENTERt kT
fLAKE PLACID__
(Place)
Name and address of nearest living relatide or name of per-on authorizing cremation_
— [R. _ $�RBAR�_KEL71X.? _._..8�4. L�L�T. • LAKE ._-PLACID, NY
--- (Name) (Address)
Name of Funeral 1-0--S-RANAC-A-VE. , LAKE PLACID
IMPORTANT:
I represent that to the best of my knowledge,the deceased(nas)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have.fuil power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,chat any personal"sessions have either been removed or may be destroyed,and agree to protect.defend and
save harmless Fine sev+i Crematorium from any and al':claims and demands for loss or damages which may be made against them
by reason of or connected with the crematlortof said remains as direoed.whether such claims or demands are or are not wholly
groundless,false or fraudulent.
2310_ SARANAC _AVE_.�_LAKE,_PLAC_ID, NY 12946
(Witness) (Address)
-. 25ACORIq ST•._c_. LAKE _PLACID, NY 12946
(Signature and Address elative or-Lega!Representative)
signed on this date:_D E C E M B E R
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the nr;�:rnated rerteains as fbslcws:
Mail to
M B._CL ARK
.....-INC.•........-_._...._._...—_
._- ..
_.-__._-231D--SAR.ANAL—AV-E-.-,--"--L&KE--P-IIACJ-D-.---_NY 1-2-9-46------
Other arrangements-Pleaseit pulverization of cremated remains is requesters,check o he e X"X._.._._
Revision:January 1,2006
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 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"signed by the nearest next of kin is necessary 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 Cemetery and Crematorium from any and all claims and demands
for loss of damages which may be, mqr,-je against them by reason of or connected with
the cremation of said remainsand/o.,disposition of said remains as directed,whether
such claims are, or are not wholly groundless,false or fraudulent.This authorization in
addition to a regular burial permit rnust accompany the remains.
3, All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material. 14o styrofoarn or plastic containers will be accepted.
4. Cardiac pacemakers, defibrillalors or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
Burial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via'Registered U. S. Mail within three days of cremation to the funeral home
handling the serJce �jnless other arra7qemeMs are made. There will be a $30.00 charge
for this service.
6. Cremation, Administration Costs and Re—cording Fees:
Adult $325.00
Children (age 13 months to 12 years'; $175.00
Infants (stillborn to 12 months) $125-00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations �50.00