Rossnen, Rosemary OF QUEEVBUP,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director
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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:
ktp�'f'y , eo'eSwn2 Female
(Name) (sex)
470 Harvey Rd. , North River, 12856
(Street) (City) (state) (Zip Code)
who died on 22 day of June 2006
at 3809 Main St . , Warrensburg, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Edythe Monroe 470 Harvey Rd. , North River, NY
(Nam) (Address)
Relationship to the deed Daughter
Name of Funeral Home Alexander Funeral Home, Inc. , North River
IMPORTANT:
I represent that to the best of my ioiovrledge,the deceased MXor(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 suffwh atfon to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that arty personal possessions have ekher been removed or may be destroyed,and agree to protect,defend and
save harmless lie View Crematorium from any and aN dakm and demands for loss or damages which Rey be made agaffkst by reason cremation
ed with the of said remains as directed,whether such claims or demands are or are not wholly
m
grou ,false
�f �iVitls.cvAA �f . /Y
Hess) (Address)
North River.
S,� kraftxe
-,and' 'Adddress of�Relative or t Representative)
signed on this crate: 0 6/2 2/2 0 0 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: R t n to Alexander Funeral Home
If pulverization of cremated remains is requested,direct here X _
Revision:January 1,20d6
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 aut>mritY 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 ar may be destroyed and agree to protect,defend and save
harmless Pixie View Cemetery and Crematorium f m any and all claims and demands
for loss of damages which may be made against them by reason of or connected with
the cremation of said remains and/or dispos n of said remains as directed,whether
such claims are, or are not wholly groundless,false or fraudulent. This authorization addition to a regular burial permit must accompany the remains. in
3. All remains must be in a casket or suitable aiiemate container.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers,defibn1lators 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
Burial Transmit Permit and Authorization to Crenate 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 (stillbom to 12inorit4s) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00