Clark, Mildred �oTVN OF QUEEN,
BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name� clk&
L Case # p2d�j'
Date of Cremation p�
Time Cremation Started
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Time Cremation Completed c� �d /�/(� 1
Type of Container G/'MYj 4/?D
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:
Mildred L. Clark Female
(NAME) (SEX)
Skilled Facility McClellan Health Systems Cambridge, NY 12816
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 27th day of April 20 00
at Skilled Facility McClellan Health Systems Cambridge,NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Harry M. Clark 142 County Road 70 Greenwich, NY 12834
Relationship to deceased Grandson
Flynn Bros. , Inc. — Schuylerville, NY 12871 Y
Name of Funeral Home ,t
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IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her ;
body. (CIRCLE ONE) •.r
.1?mthe `
I certify tAat I have the full power and authorization to arrange for the cremation of the remainF
to direct the disposition of the cremated remains, that any personal possessions have either'
removed or may be destroyed, and agree to protect, defend and save harmless Pine
Crematorium from any and all claims and demands for loss or damages which may be m
the cremation of said remains as directed, w .
against them by reason of or connected with i
chtclad not wholly groundless, false or fraudulent. J.
13 Gates Ave. Schuylerville, NY 12871
(ADDRESS)
142 County Rd 70 Greenwich, NY 12834
RE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: April 28, 2000
*r►
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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: Will Pick Up
If pulverization of cremated remains is requested, check here XX
- - 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.*
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
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 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,
f 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
Ori ccntainers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
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6- The q iestion relative to Cardiac pacemakers must be answered on the authorization to
..r, rr,` form before the remains will be accepted.
6. less other arrangements are made the cremated remains will be mailed via Registered
i. Mail within three days of cremation to the funeral home handling the service. There will
a 520.00 charge for this service.
4
ition, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
ars) $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.
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