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Tennant, Robert T0UN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director A k Name r;AOBF,)ZA `rE�JiJg74 Case# Date Of Cremation - 'Z (�— `z-0C� Time Cremation Started �=�j O 31 -" Time Cremation Completed 6 `3 Type of ContainerG�17-<)- A�j--,N2.-j Remarks /Vl sS i 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: Robert C. Tennant Male (NAME) (SEX) 28 Horicon Avenue, Warrensburg, New York 12885 (STREET) (CITY) (STATE) (ZIP CODE) who died on the 11th day of February 20 03 at 28 Horicon Ave. , Warrensburg, New York 12885 (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Robert Scott Tennant — 37 State Rt 28. Warrensburg, New York 12885 Relationship to deceased F Son Name of Funeral Home Al Pxanrlar FiinPral Hump Tnr IMPORTANT I represent that to the best of my knowledge, the deceased SIX . has no pacemaker in his iKm 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 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 such pkikms or demands are or are not wholly groundless, false or fraudulent. hn S. Alexander, 3809 Main St, Warrensburg, NY 12885 (WIN Robert �— Robert Scott Tennant 37 State Rt 28 Warrensburg, NY 1281 (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: -)"" iq-0� DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arran9 ements-please specify: L YYl If pulverization of cremated remains is requested, check here POLICIES, RULES AND REG ILATIONS 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 ►je made for Saturday. Pre-arrangements by telephone for acceptance of remains is necessan, " 2. Pine View Crematorium is located on the grounds ,)f the Pine View Cemetery, Quaker Road, Town of Queensbury. 3. An authorization for cremation properly signed b/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 -,nd all claims and demands for loss or damages which may be made against them by reaso!i 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 frat :ulel'1t. This authorization in addition to a regular burial permit must accompany the remai,is. 4. All remains must be encased in a cas!.et or suitable alternate container. Caskets and containers must be of combustible m::terial. No Styrofoam or plastic containers will be accepted. 5. The question relative tc cardiac pa,.amakers must be answered on the authorization to cremate form before the remains will be accepted. 6. Unless other arrangements are r iade 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 arTd 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.