Harr, Lawrence TOWN OF QUEEN,5BUJ�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director SdAil9
Name /,4&)g ACjEo' j Case # Zjeor� l
Date of Cremation
Time Cremation Started
Time Cremation Comoleted
1 17
Type of Container � c�/y17, C A-5� 6J� / �114F-04/
Remarks :
r TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM /r
Quaker Road, Queensbury, New York 12804u
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:
lhl� E r
(NAME) (SEX)
//5- 11AeaLA✓ ,4✓E, SAS 5)9?JaGs1,� Ny /z S*C-d'
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 2��.I� day of �`'`Ly 20_ /
J I,
atT-9
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
/'�/�S / 3�'Tlfi �� /YSL� oG� ✓E;sAasfT �, c,�.vy
Relationship to deceased
Name of Funeral Home �//�Ai"► �' �t,�,QkE�- DNS
IMPORTANT
I represent that to the best of my knowledge, the deceased _ has no acemaker in his or her
body. (CIRCLE ONE) 4 I certify that I have the full power and authorization to arrange for the cremation of emains and ,
to direct the disposition of the cremated remains, that any personal possessions of
been
removed or may be destroyed, and agree to protect. defend and save harmless Pine View r'z
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 as directed, whether 3
such lai s or de ands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
� n
�a,(kf�— Z") -
E OFF RELAT OR LEGAL REP. AND ADDRESS)
Signed on this date: // /�
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-:)lease specify: gwza-s W1 GG P/
djiw
If pulverization of cremate:; remains is requested, check here
f
. " POLICIES, RULES AND REGULATIONS
t
f
—� "t—'The crematorium vAl be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. No Holidays cr Sundays, arrangements can be made for Saturday. Prearrangements
A by telephone for acce;.tance of remains is necessary.`
2. Pine View Crematoriutii is located on the grounds of the Pine View Cemetery, Quaker Road,
— - Town of Queensi�.ry
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
:crtC:i: 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
r 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
11 ..-'a'ccepted.
iedi is iues,ion relative to cardiac pacemakers must be answered on the authorization to
--nate.form before the remains will be accepted.
Intess other arrangements are made the cremated remains will be mailed via Registered
r , ;. , I
Mail within ;n-ee days of cremation to the funeral home handling the service. There will
be a $20r00 charge for this service.
Cremation,`kdministration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 yeirsj $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.