Holley, John (-"(-I YYN OF QUEEVBUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Lh 11ZH11
Name I ( ��� Case# 2 �j
Date Of Cremation _ � — god
Time Cremation Started
Time Cremation Completed
Type of Container-61u'0'01^�CQ
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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 rei�ti'.and authorizes Phis View Crematorium,in acx ordanc a with mid stA*d to its Rules and P.egulatians to
cremate the remains of:
JOHN C. HOLLEY Male
(Sex)
Indian Pass Ranch Lake Placid, NY 12946 _
) -- (city) (Stage) (zip )
of� June 06
who died on 7 t h �--------
NY
at Adrk Medfcal Center,( ,5 )anac Lake, _ ,�.__.
(Place)
tdame and address of nearest riving relative or name of person authorizing cremation:
Tnd; Il Pass Ran h. a .Plaid, NY
_-•'�f r s .(Name)e) (Address)
RelatiorishlO to ttie deceased-_*10 f - `-
Name of Funeral Home M B Clark, Inc. Lake Placid, NY
IMPORTANT.
re represent that to the best of my knowledge,the deceased(has) (has no pacem*er.�or arty O#wx battery operat
I ed
device in his or her-body (Circ'is one)
I Certify that t have:fuli power area authorization to arrange for the cremation of the remains and to dim g td��ti�fdefend and
cremated remains,that any personal possessions have either been removed a may be destroyed. he made against them
• save he Pine V'�Cirematortum fioin any and all dalms and demands for loss or daritagas which may
by reason of'o'r coirnected wrih the cremation of said remains as direoed,whether such Mims a demands are or are not wholly
groundise or fraudulent.
1011 2314 �3ranac Ave. - , Lake_Placid, NY 12946
(Address)
n (Witr �
Indian Pass Ranch, Lake Placid, NY
(Signature a Address of Relative or regal RepreseraWive)
Signed on this date:„ Jane 8 , 20.06
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the Cremated remains as follow.
Mail to
other arrangements Please specify: Fun' 1 Home will ick-Alp cremains
i .
if pulverization of cremated remains is requested,deck hereXXX
• Revision:January 1,2tK16
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 made against them by reason of or connected with
the cremation of said remains and/or 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 must accompany the remains.
3. All remains must be in a casket or suitable alternate container.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�Reglstered U. S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a $30.0O 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 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00