LaHart, Kathleen OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12804
Cemetery Office:(W)745-4476, Crematorium: (518)745-4477 ....
Authorization to Cremate
The undersigned rb*jest§and authorizes Pixie View Crematorium,in accordance with and sty
to its Rules and Rtrgulations to
Cremate the remains of
Kathleen D. LaHart Zama
(N —�
Gran-c r r ' p P l a r•i d (Swe) Code
1 )
(Street) (Ctty) `.,...
7 th day of- Jun e -- -----
who died on ^_
at-'(P )' rem)
Name and addiess of nearest living relative or name of person auftw zirtg cremation:
• �randvi eSd Ay r aJe11 7-d, NY
(Name) (Address)
Relationshio tb tWdeoeesed_._
Name of Funeral Home M B
IMPORTANT: the ( )or(has rx>)pale' dplbripstor or any other bane3ry operated
I represent that to the best of my krtoNrledge,
device In his or her.body. (Circle One)
I certify that I have power and authorization to arrange for the cremation of the remains and to direct ft may be made ago td� otect defend and
cremated remains,fhat any personal possessionshave either claim s and demands for been removed of may destroyed, against them
save harmless Pk► .V00 Crematorium atom any and all claims loss o o r damages wtscrt
by reason o1'or Connected with the cremation of said mnuMs as drferted,whether such dolma or demands are or are not wholly
groundk"Ise Or fraudulent.
2310 ,Sa anac Ave. ,_Lake Placid, NY 12946
(Address) —
-Lake Placid, NY
(Signatur nd ddress of Relative or Legs#Representative)
Signed On this date: ja n P A n 0-6--
Disposition of Cremated Remains
i hereby direct Pate View Crematorium to dispose of the cremated remains as fdlOws:
Mail to_NI.. _B. -C 1 a r k, Inc -
-ZU-0 Sa aI13S`Aver_T,akP Pl�,acy�_d NY_._.129! ..-.---
Other arrangements-Please spedfy: - - -`-T
if pulverization of cremated remains is requested,died*here 4' Cam_
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. 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 who&, groundless,false or fraliduient.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 styrofoarn 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 vie Registered.U. S. Mail within three days of Cremation to the funeral home
handlintj'the service unless other arrangements are made'. There wile 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 months) $125.U0
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00