Zarczynski, Lauren (-ro 7+N OF QUEENB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Dire ctorAA� ADZ;'
Name /, /� Case # j
Date of Cremation A&
Time Cremation Started
Time Cremation Completed 1 n ✓�� P Ir ' 1
Type of Container /7f7,f fJdp U C �,�T •��jrC/� cgl�7/�1,�'���
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
Lauren Zarczynski Female
(NAME) (SEX)
Apt. 14; Heritage Apartments, Glen St., Glens Falls, N.Y. 12801
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 24th day of October �- 20'00
at the Glens Falls Hospital
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing crematicwn y
Mrs. Margaret J. Zarczynaki — 47 Prospect St., Warrens 12885
Relationship to deceased Mother
. ,. ;T�,lr5r-
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Name of Funeral Home Alexander Funeral Home, Inc. i7`? ;sil�d
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IMPORTANT �ajggoos
I represent that to the best of my knowledge, the deceased Jg=has no;paFRauks Sffi her
body. (CIRCLE ONE) ,o 91Gf'191�
I certify that I have the full power and authorization to arrange for the cremation,of thergg��nna.u�s and
to direct the disposition of the cremated remains, that any personal posses,qb h �'`ithe�"been
r destroyed, and agree to protect, defend and save harrtllesv /I w
removed o may be y g p . ��� 4 ,
Crematorium from any and all claims and demands for loss or damages-vih nade
against t4emby re on o r connected with the cremation of said remains as directed, whether
such clai s o e an re or are not wholly groundless, false or fraudulent.
809 Main St., Warrensburg- N.Y. 12885
(WITNESS) (AD SS)
�- 47 Prospect St. Warrens N.Y. 12885 �
I AT RE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 10/25/00
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: Give to Funeral Director
If pulverization of cremated remains is requested, check here XR
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M. Monday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements
by telephone for acceptance of remains is necessary.*
"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
a Iverson 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 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 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---AW-Fernains 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 must be answered on the authorization to
cremate form before the remains will be accepted.
106.� 1 lhleig tither arrangements are made the cremated remains will be mailed via Registered
-I e r,- -UU:•S.--Mail within three days of cremation to the funeral home handling the service. There will
.y az 'be=aV,0.00.charge for this service.
111"1 Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to 12 months) $75.00
* Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.