Stark, Mariam rl-O%N OF QUEEVBU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case # sl
Date of Cremation c'
Time Cremation Started
Time Cremation Completed 3l 3 0 '��
Type of Container C-4 Kg
Remarks :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: Will Pick up
If pulverization of cremate remains is requested, check here XX
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
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
t. This
not wholly g a dless, false or regular burial permit mustnaccompany athe o rization in
addition to a 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 crematediac form before the ers must
rema ins will answered
be
on the authorization
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered
U.S. Mail
within
hree dioce1
on
to the funeral home handlingthe service Therewllbea $2500
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 $100.00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional a wi0101•00 Any remains recive after be charged an additional $100 003.30
P.M. Mon-Fri or Saturday
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
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:
Marian E. Stark Female
(NAME) t t (SEX)
57 Green Street Schuylerville, NY 12871
(STREET) (CITY) (STATE) (ZIP CODE)
27th November 02
who died on day of 20
at Saratoga Hospital 211 Church Street Saratoga Springs, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Grace Iloyd PO Box 114 Rt 32- Victory Mills, NY 12884
Relationship to deceased Daughter
Name of Funeral Home Flynn Bros. , Inc. - Schuylerville, NY
IMPORTANT
1 represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
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
.e matorium 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
such claims or demands are or are not wholly groundless, false or fraudulent.
CA."v'. P 4230 Garden Street Titusville, FI 32796
(WITNESS) DDRESS)
A-'A-vY 9/d PO Box 114 Rt 32 Victory Mills, NY 12884
(SIGNATURE OF RKATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: Nov. 29, 2002.