DeVoe, Lloyd rrO gtiN OF QUEEN4,5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director & �(/g/`(jJ�
Name X/,-0y-o Doh Case # Q1JQ1
Date of Cremation Y - oZ,3 ` oZCX21
Time Cremation Started f4 .�' a-a— od/M I
Time Cremation Completed f t2J '�o E" M ,
Type of Container C&W&i RD /$`T cz��.Q C nLk � Y
Remarks :
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t17, P� M `
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crenj4t9riwM,J45-4477;(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:
Lloyd E. DeVoe Male
(NAME) (SEX)
149 Roading Branch Rd, Stony Creek, NY 12878
(STREET) ':.(CITY) :- : (STATE) (ZIP CODE)
who died on 20th day of April 2001
at his home, (same as above)
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
Barbara DeVoe, Same .as: above
Relationship to deceased,..;l, • •Wife
Name of Funeral Home Alexander FH, Inc. , Warrensburg, NY
IMPORTANT
I represent that to the best of.my.knowledge, the,deceased. r has no pacemaker in his or her
body. (CIRCLE ONE)
I certify;that I have;ihe,full pqW,ettd.aull�eti9P;toaf��n s, ,,the.cremation of the remains and
to direct the d'Isposition;0;t [ #ets. ftli�iit(aty4FA( oal°possessions have either been
removed or may be destroyed, and agree to--protect, deferac�;a�disave:harmless Pine View
m from any and all claims and demands for loss or damages which may be made
7againsmby reason ofor.coranected with the,cremation of said remains as directed, whether
s or demands are or are not wholly groundless, false or fraudulent.
Warrensburg, NY
(WITNESS) , ;(ADDRESS) ,, .
It ,/t I / Same as above
L
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: �/ 2 d' U
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium 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 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. Prearrangement-
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 authorizea
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 possession
have either been removed.or may be destroyed.and.egree 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 art
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 must 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 Registered
U.S. Mail within three days of cremation to'the funeral home handling the service. There wni
be a $20.00 charge for this'service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months tc
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.