Ashdown, Bradford OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name r�• ;c`���� �S�.�I Case#
Date Of Cremation 3 It 3%v b
Time Cremation Started_
Time Cremation Completed_ P"
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Remarks
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Town of Queensbury
Pine 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
f3R�d F �P d �s�dow�J 1.410,
(Nam)) ' �1 / (�) l� (,
1,2( 16d- � �OC �i9�,4y�-9 �P2�w£ AlJ 1o?d G.1
(Street) /� (City) (State) (Zlp Code)
who died on // a(o /day of //�/t% 20 OG
at )/9il/l�ac,/9 �lfD/ W SA/lFJ15�gA -�f�izi�tjJ �1'
(Place) (Address)
Name and address of nearest living relative or name of person authorirzkV cremation:
5��,r, �, �s44!L-� /,?C ��� /�o�, �,ono�
(Name) // • /-(Address)
Relationship W the deceased Gam/C-•- /
Name of Funeral Home
IMPORTANT:
I represent that to the best of my kuhowledge,the deceased(has) ro,jJlravpacemaker,defibrillator or any other battery operated
device in his or her body. (Cade One) '�
1 certify brat t have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,90 any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save Farmless ire aWrk"from any and aN ckakns and demands for loss or damages which may be made against them
by reason of or sect h c rerru lion of said remains as directed,whether such claims or demands are or are not wholly
groundless, or
(Witness} (Address}
(Signature and 7Y72T-e-120,�
r to Rep i-Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: ie l v 115, /`/li�rA 105-111
If pulverization of cremated remains is requested.check here
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.P+eararKJementsore
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 pions
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
€or loss of damages which may be made against them by reason of or connected with
the cremation of said remains artdkx disposition of said remains as directed,whether
such claims are, or are not wholly groundless,false or ftudulent. This authorization in
addition to a regular burial Permit must accompany the remains.
3. All remains must be in a casket or suitable alternate contain.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac Pacemakers, defibrillators 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 service unless other arrangements are made.There wilt be a$30.00 charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12,xnonths) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 00