Barney, Marlene rrnWN OF QUEEMB U�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/ Funeral '/Director ) r Ck��k
Name �, �jC /1�, Case # �34
Date of Cremation
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Time Cremation Comoleted, •gc Jf r ArnJ
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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 745-44.76
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:
Marlene J. Barney FEMALE
(NAME) (SEX)
82 River St. La%e Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE)
Sixth July 20 01
who died on day of
at 82 River St, Lake Placid, NY 12946
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Chris Barney 82 River St. Lake Placid, NY
SON
Relationship to deceased
r
Name of Funeral Home M.B. Clark Inc.
r, ..
IMPORTANT
represent that to the best of my knowledge, the deceased has o as no acem;l in, .9r,-herd
body. (CIRCLE ONE) ?v�o
I certify that I have the full power and authorization to arrange for the cremation.of the re and
to direct the disposition of the cremated remains, that any personal possessions,haue,pither I en
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 whidh may die made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims r demands are or are not wholly groundless, false or fraudulent.
- / ,- _
(W ) (ADDRESS)
NATUR OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signe n this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to » 6 C 44/z Z< ?rt%
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here a-
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. Pre-arrangements
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 authorized
person stating that they do have the power and authority to arrange for the cremation of the
W.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.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
brs :,,.
n915'-Of:iess o'thef arrangements are made the cremated remains will be mailed via Registered
U.S. M&I within three days of cremation to the funeral home handling the service. There will
iG,.
ii*,a $25.GO charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $150.00 Infants (stillborn to 12 months) $100.00
" 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.