Long, Helen '7"'WN of QUEEVBU-IPky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
,�/ Funeral Director f 61-CCt
Name ) �64P' -6 yy Case # 474/
Date of Cremation 3 - c-k- acdo
Time Cremation Started 4LfhtO Arm r
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Time Cremation Completed /9 rAA f
Type of Container
Remarks : — I
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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
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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:
Helen Long Female
(NAME) (SEX)
38 Cascade Road Lake Placid , NY 12946
(STREET) (CITY) (STATE) (ZIP CODE) - -'
who died on 27tr day of 2000
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at 38 Cascade Road, Lake Placid, NY 12946 __;_:7 . tt . F
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cre nation, .., -"�'�q
Mrs . Barbara Rine G ,r s
� 622 Green Street, .,�t1.S�`��:_ .�PrT�"S .,
Relationship to deceased Dataghter
Name of Funeral Home M B Clark, Inc 27 ��arana'c
NY
IMPORTANT .9. ,. .
I represent that to the best of my knowledge, the deceased has or•fi_as�o pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of Ih9 j d
to direct the disposition of the cremated remains, that any personal possessions have ei er been
removed or may be destroyed, and agree to protect defend ar>ti save�W s� j RYV ,a
Crematorium from any and all claims and demands for loss or darraa�es wh cna ,b �,���.M
against them by reason of or connected with the cremation of�said ream it$as 1ire�:taed;r ! r
such claims or demands are or are not wholly groundless,false oxJraudu)?nt
Fake Placid , NY
(WITN S) (ADDRESS)
4_-,, _/6� ;2e;Z:�44 622 Greeri St. kliSab14 For'
(SIGNATURE OF RELATIVE EGAL REP. AND ADDRESS)
Signed on this date:, 227 2-CO C- y
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to N B C1.ark, Inc. 27 Saranac Avenue, Lace Placid, NY 12946
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Other arrangements-please specify:
I1p4lverization of cremated remains is requested, check here y
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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.* I
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,statirig_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. 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.
790 to ail'ha esstic ntdati, ve_.10 carca� c: acemakers must� _. ._ ... p be answered on the authorization to
cremate form before the remains will be accepted.
bns &irrbnlesd�6therarfangem6nts`are,made.the cremated remains will be mailed via Registered
nssd i9�t�S. ril aui ree.�ays of-.cremation to the funeral home handling the service. There will
te:`a $20.Wcharge forthi"s+service.,
',---,amatioh,Administratort Cbsts and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 tnfants`(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.