Powell, James rf-o WN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -,EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��to H�E abl)G-�
Name IJCjQ �� Case # UAL
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Date of Cremation
Time Cremation Started
Time Cremation Comoleted
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TOWN OF QUEENSBURY
pINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 77454447677 or if no answer
Cemetery
AUTHORIZATION TO CREMATE
in
The undersigned req�e5sub�ect authorizes
Rules View
and RegulationsCrematorium,
to
accordance with a
cremate the remains of:
James Powell Male
(Sex)
(Name)
Camp Gabriels Correctional Facility Route 86 PO Box 100 Gabriels New York 12 stat -e) (Zip Code)
(Street) (City)
18 January xlxgx 2002
who died on day of
at Adirondack Medical Center Saranac La
- New York 129-8-3—
(Place) (Address)
Name and address of nearest living
relative or name of person
authorizing cremation: Camp Gabriels Correctional Fcility
Dr . Herbert Bergamini PO Box 100, Gabriels , New York 12939-0100
(Name) (Address) Representative for
Relationship to the deceased
New York State Department of Correction
Name of Funeral Home
Fortune-Keough Funeral Home, Inc.
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
1 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,
efend
and save harmless Pine View Crematorium from any and all claims j
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 such claims or demands are or are not wholly
groundless, fa se o fraudulent.
ent.
Saranac Lake 1
40 Church St . , New York 12
twit ss) /� CamP drG�absriels Correctional Facility
tiwc�` PO Box 100, Gabriels , New York 12939-01
(Signaturd of Relative or Legal Rep. and Address)
January 24, 2002 it
Signed on this date :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Fortune-Keough Funeral Home, Inc.
Church Street Saranac Lake, New York 12983
Other arrangements - please specify:
If pulverization of cremate 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. Prearrangements 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 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 of 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 styrafoam 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 $20 . 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 .00
Children (age 13 months to 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 .