Palmer, Lawrence TOWN OF OUEENSBURY
PINE VIEW CEMETERY
a
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 touts Rules and Regulations to
cremate the remains f: /fin
(Name) (Sex)
f� s s e X Ny- ,
(Street ) .(City) (State) (Zip Code) !�
J� day of G 19 <�
who /died o/n�
f.17 'lee
(Place) (Address)
Name and address of 6earest living relative or name of person
authorizing cremation: a /
L- 6'�ie 1�- A
T (Name) (Address)
r
Relationship �o the'deceased
Name of Funera 1 Hoe
f
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no paceoaker 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 o may be destroyed, and agree to protect, defend
and save harmle s 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 as
directed, whet er suchjclaims or demands , are or are not wholly
groundless, fall or fraudulent.
j
(Witness) ( (Address)
(Signature oll Relative or Legal Rep. and Address)
Signed on this da4 : 71.;2 S
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 Iremains 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 lthe grounds of the Pine
View Cemetery, Quaker Road, Town of Queen bury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person st4ting 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 ar►� save harmless Pine
View Crematorium from any and all claims ant demands for loss of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or isposition of said
remains as directed, whether such claims or i.emands 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
material. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemaker must be answered
on the authorization to cremate form before the remains will be
accepted.
6. Unless other arrangements are made the ere ted remains will
be mailed -via Registered U. S. Mail within three ayli .of cremation
to the funeral home handling the service. Ther will be a $20. 00
charge for this service.
Cremation, Administration Costs and Recording F e: Adult $ 185. 00
Children (age 13 months to 12 years) 6110.00 nfants ( stillborn
to 12 months) $70. 00