Benway, Len TO`14N OF QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director fze✓/ p_
Name Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed '� j
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Type of Container
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Len Michael Benvay Male _ -
(Name) (Sex)
2067 Call St. Lake Luzerne,_ #Y_ 12846
(Street) (City) (State) (Zip Code)
who died on 7th day of March _ _____ 99
at Glene Falls Hospital Inn Pork Street SienaNY-12a0
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mr. Cliff 0. Benvay 2067 Call St. Lake Luzerne , NY 12846
(Name) (Address)
Relationship to the deceased Father _ _-
Name of Funeral Home Carleton Funeral Hone Inc
IMPORTANT:
represent that to the best of my knowledge, the deceased has or 6has no
pacemaker in his or her body. (Circle One)
certifyt a f nd authorize t�, �r ,A for th cremation_
l r ` fl ��� .� q?R) meet� � ny -
of the remains and to erect a isposition of the cremated remains,
personal possessions have either been removed or may be destroyed, and agree
to protect, defend and save harmless Pine VieW Crematorium 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 not wholly groundless, false or fraudulent.
Uk68 Main St . , Hudson Falls , NY 12839
(Witness) (Address)
2067 Call St , Lake Luzer__ne_, NY 12846
�fiatu of Relative or Legal Rep. and Address)
Signed on this date: ' S
DISPOSITION OF CREMATED REMAINS
hereby direct Pine View Crematoriurn to dispose of the cremated remains as follows:
Mail to ---- -- ----- ——
Other arrangements - please specify:
If pulverization of cremated remains is requested, check here----
POLICIES, RULES AND REGULATIONS
1 . The crernatorium will be open for cremations 5 days a week 7AM--3:30PM Monday-
Friday. No Holidays or Sundays, arrangements can be made for'Saturday.
Prearrangements by telephone for acceptance of remains is necessary.
2. Pine View Crematerlum is lec sted on the grounds of the Pine View Cemetery,
Quaker Road, Town of Queensbury.
3. An author.iption for cremation properly signed by the nearest next of kin or other
authorized person' steting'that they do fiave 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 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 and/or disposition of said remains
as directed, whether such claims or demands are, or are not whoHlr jrowdless;!,
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 styra'foam or plastic containers
will be accepted.
5. The question relative to cardiac pacemakers trust be answered on the
authorization to cremate form before the remains will be accepted.
6. Unless other arrangements are made the cremated remains will be mailed via
U.S. Mail within three days of cremation to the funeral home handling the service.
There will be a $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $1,75.00
Children (age 13 months to 12 years) $100.00
Infants (stillborn to 12 months) $60.00