Korenyik, Tibor rrO RN OF QUEEN,5BU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,9',C,,�X�}���,p
Name / O Case #
Date of Cremation y `C C2�- /
Time Cremation Started /9 fM/
Time Cremation Completed r yrQ rm
Type of Container Jc )o G19'5 A Z: 19: o -/2icOj9y
Remarks :
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�29 IA
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TOWN OF QUEENSBURY
PINE
A VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone.(518) CrerR;%9(iWM!?745r4477;(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:
Tibor Korenyik Male
(NAME) (SEX)
PO Box 522, Jerry Savarie Road, Indian Lake, New York 12842
(STREET) .(CITY) (STATE) (ZIP CODE)
who died on The 29th day of June 20 01
at The Glens Fa11sj, Q pital-- Glens Falls, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
Mrs. Virginia 1-7,oxenyi'h — P0- •'Bc x 522, J-er' -Savarie Rd, Indian Lake, NY 12842
Relationship to deceased ;;W3-ie
Name of Funeral Home Alexander Funeral. Home, Inc. , 4479 St. Route 28, North River,
12856
IMPORTANT
I represent that to the best of.my,knowledge, the deceasedr has no pacemaker in his or her
body. (CIRCLE ONE)
I certifyrthat I have the,fu.(I RpWRnstaulzetign;.to;,w,feggq�;;�q�ythe.c(emation of the remains and
to direct the.disposition; ; tp tedcf t In aftny4VA0 @o po sessions have either been
removed or may be destroyed, and'agree fo protect, defer�d�;andfsave:harmless Pine View
Cre atonum from any and all claims and demands for loss or damages which may be made
gains t hem by reason of or.connected with rthe,cremation of said remains as directed, whether
such c i r demands are or are not wholly groundless, false or fraudulent.
r
7_4479.,State Route 28,, North River, NY 12856
(WITNESS) (ADDRESS) .
'� j PO Box 522, Jerry Savarie Rd. , Indian Lake, NY 12842
(91GNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: June 30, 2001
• f a
DISPOSITION OF CREMATED REMAINS
I hereby direct Pire View Crematorium to'dispose of the cremated remains as follows:
Mail to
Other arrangements-piease specify: Return to Funeril Director
If pulverization of cremated remains is requested, check here X
POLICIES, RULES AND REGULATIONS
1. The crematorium :rill 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. Prearrangeme—
by telephone for acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Roa
Town of Queensbl;y
3. An authorization fcr cremation properly signed by the nearest next of kin or other authorize
person stating that they do have the power and authority-to arrange for the cremation of th,
remains and to direct the disposition of the cremated remains, that any personal possessior,.
have either been removed or.may be destroyed_and.agree to protect, defend and save
harmless Pine Via,; 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 , r
or are not wholly g:oundless, 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 befc;e ,ne 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 crematidn to the funeral home handling the service. There v,
be a $20.00 charge for this'service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months
1'2 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.