Lefebvre, Frances TOWN OF QUEENSBURY
Pine View Cemetery and Cremntorhini
21 Qunker Rond, Queensbury, NY. 12804-5902
(518) 74 5-4476 (518) 745-4477
htcp://wNvw.queensbury.net
Funeral Director: 10
Name of Deceased: /� G� F fJ V)�
Case Number: U�O 0
Date of Cremation:
Retort: ORA V 9)
Time Cremation Started:
Time Cremation Completed: N`
Type of Container: 014g,J zvI ' ,,y,,12 fd '}2,-rj
Remarks:
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" Home of NntitrnI Beauty ... A Coot PInie to Live "
0 TOWN OF QUEENSBURY
PINE VIEW CE'METERY
CREMATORIUM
Quaker Road, QueensbUry, New York 12804
Phone(518) Crernatoftrn 745-4477 (if no answer)
Cemetery 7�5-4476
AUTHORIZATION TO CREMATE
'nieundersigned requests and aLlt,110rizes I'Dine View Crematorium, in accordan e with afidsubject
to its Rules and Regulations to cremate the remains of:
J';
Frances Lefebvre Female
(NAME) (SEX)
185 Old .Militar)L ,,Road, Lake Placid, NY 12946 &
'STF
ZEET) (CITY)
(STATE) (ZIP CODE)
who died on day of
lith ji, y 4,flUb
at [Jihlein Mercy Center Lake Placid, NY
(PLACE) (ADDRESS)
flative or name of person authorizing cremation: f
Name and address of nearest living rL
Gail Pelkey, 89 Greenwood St. , Lake Placid, NY
_7 I
Relationship to deceased- Daiighter
Name of Funeral Horne M B Clark, Inc. , 2310 Saranac Ave. ,
Lake Placid, NY 1290 '
IMPORTANT
I represent that to the best of my knowledge, the deceased has o pacemaker imbf,� or her
body. (CIRUE ONE)
I cerfify that I have the full power and authorlzation to arrange for the cremation of the re nrithins and
to direct the disposition of the cremated rernaIns, that any persona) possessions have e'h�r been
r'emoved or may be destroyed, and agree to protect, defend and save harmless Pine Vif"
Crematorium from any arid ail clairris and demands for loss or damages which may be rbade
against them by reason of or connected with the crernation of said remains as directed,W16,ethe(
such clair 9 or dernands are Drare not wholly groundless, false or fraudulent,
2310 Saranac Ave. , Lake Placid, NY 1ZO- 46
�WTNES-S) (ADDRESS)
89 Greenwood St. , Lake Placid
NY
(SIGNATURE OF7 n- -A7?7E--6R L.E(r,-- AND ADDRESS)
Signed on this date:-jiLLy-.-U4-2-QD-5----.
WSPOSITION OF CRENIA'TED REMAINS
1 here-by direct Pine View CreMBtOrkinn to dispose of the cremated remains as f0flow5'.
Me" to M --,-2-3 LO—.,5—a !f
NY __U94
Other arrangements-please specify:
ff pulvei-izatlon of cremated remains isrequested, check here
sr
POLICIE-S, RULES AND REGULATION$
1. The crematorium will be Open for cremations 5 days a week 7:00 A,M, - 3:30 P,M Klipriday.,
ii 11 1
Friday, No Holidays; or Sundays, arrangements can be made for Saturday, Prearrajigerylents
by telephone for acceptance of remains is necessary."
2, Pine View Creniatorium is located on the grounds of the Pine View Cemetery, Owak"IWIRoad,
Town of Queenshury.
3. An authorization for cremation properly signed by the nearest next of kin or other oi..111,6rized
ji
person stating that they do have the power and authority to arrange for the crernatiOn bf thf,-,�
remains and to direct the disposition of the Cremated remains, that any personal ss,i o 1)s
have either been removed or may be destroyed and agree to protect, defend and vo�s,
harmless Pine View Crematorium from any and all claims and demands for lose or faixiacleb
which may be made against them by reason of or connected with the cremation 0 said
remains and /or disposition of said remains as directed, whether such claims or de," nds are,,
or are noi,wholly groundless, 1`11se or fraudWent. This autho0zation in addition to a I ular
burial permit must axompany the remains.
4. All remains, must be, encased in a casket or suitable alternate container. Caskets aidj,
contalners ii-rust be of cornbLlStible material No Styrofoam or plastic contaillers wildbe�,
accepted.
6. The question relative to cardiac paC(-.MakPFS must be answered on the authorizatilk f��'o
cremate form before the remains will be accepted.
B. Unless other arrangerne.rits are made the cremated remains will he mailed via Re V'red
U,S. Mail within three days of cremation to the funeral home handling the service,'
'Riere will
be a $20.00 charge for this service,
Cremation. AdininiBtratiori Costs and Recording Fee: Adult $226,00 Children (age 13 nonths to
12 yeam) $115,00 Infants (stillborn to 12 months) $75,00
si
Additlartal $50,00 charge for cremations done after '100 P.M. Monday through Frida
Cremations done on Saturdays 01 bP Charged the additional $60.00,