LeJecek, Elizabeth 1
rl-o7+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1z
Name kL . CdCase
Date of Cremation 4?
Time Cremation Started ,
Time Cremation Completed , 0
Type of Containerct4y� 'AaGyt-12'<)
Remarks :
TOWN OF QUEENS6URY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine Yew Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
(NAME) (SEX)
25 Sentinel Road, Lake Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 13 th day of J iz 1 Y Zp 0 4
25 Sentinel Road Lake Placid, NY 12946
(PLACE) (ADDRESS)
Name and address of nearest riving relative or name of person authorizing cremation:
Charles Lejcek 25 Sentinel- Road, Lake Placid, NY
Relationship to deceased Son
Name of Funeral Home M B Clark, Inc. 27 Saranac Ave. , Lake Placid,
12946
IMPORTANT
I represent that to the best of my knowledge,the deceased has has acemaker 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 or may be destroyed;and agree to protect,defend and save harmless Pine View
.L`rematorium from any and all claims and demands for loss or damages which may. be made
;against them by reason of or connected with the cremation of said remains as directed,whether
such claims or demands are or are not wholly groundless,false or fraudulent.
27 Saranac Ave- , Lake Placid, NY 12946
(WITNEn (ADD SS}
Aili 2 Sentinel Rd. , Lake Placid,
(SIGNATU E R EGAL REP.AND ADDRESS)
Signed on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to M. B. Clark, Inc.
27 Saranac Ave. , Lake Placid, NY 12946
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here xx
POLICIES, RULES AND REGULATIONS
I. The crematorium will be open io
A.M. - 3:30 P.M. Monday-Friday. Holidays or wSundays,
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person 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
Crematorium front 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 or demands 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 Styrofoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers ust be answered
on the authorization to cremate form before the mremains will be
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremation
to the funeral, home handling the service. There will be a $25.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $300.00
Children (age 13 months to 12 years) $150. 00 Infants (stillborn
to 12 months) $100. 00
Additional $100.00 charge for cremat'�aria
\pday through Friday. Cremations done o
rged the additional $100. 00 Any rema a will be
Mon-Fri or Saturday will be charged an . 4 after 3:30
100.00.