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Moran, Alvin �oq+N OF QUEEN BUJ�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, -,EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name (�/ i/� /V,I� /g Case # Date of Cremation /C- ` Time Cremation Started—z-� P, j Time Cremation Completed - //Vl 1 Type cf Container /�/fP /// Remarks : , 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: Male _ AT VTN P M= (NAME) (SEX) 102 Cross Rd. Warrensburg, N.Y. 12885 (STREET) (CITY) (STATE) (ZIP CODE) who died on 22 Ad. day of Dec. 2001 at 102 Cross Rd. , Warrensburg, N.Y. 12885 (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Jennifer A Moran 340 37 Th. St. Lindenhurst, N.Y. 11757 Relationship to deceased Daughter Name of Funeral Home Alexander Funeral Home Inc IMPORTANT I represent that to the best of my knowledge, the deceasedAor has no pacemaker in his or he. body. (CIRCLE ONE) I certify that I have the full power and authorization 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 Crem tonum from any and all claims and demands for loss or damages which may be made ainst t em by reason of or connected with the cremation of said remains as directed, whether such cl ms or demands are or are not wholly groundless, false or fraudulent. John S. Alexander 3809 Main St. , Warrensburg, N.Y. 12885 4(S1 S (ADDRESS) �37 Th. St. Lindenhurst, N.Y. 11757 � TU E OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: l 2- —Z-a—O t 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. 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. 1, 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 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. FAIT 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 will be a $25.00 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.