Hier, Evelyn (-r0WN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date Of Cremation 01
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Time Cremation Started
Time Cremation Completed � ` b Jti,
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TOWN OF QUEENSBURY Z
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:
(NAM t (SEX)
_ o
(STREET) (CITY) (STATE) (ZIP CODE)V OS27
f�
who died on day of 2003
at / f VT
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased l�l�.St� �v✓}�t
Name of Funeral Home
VT
IMPORTANT "'
I 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
d—rematodum 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 ar or re not wholly groundless, false or fraudulent.
(WI SS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: De(' 0-3
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 cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematoriumwill be open for cremations 5 days a week 7: 00
A.M. 3:30 P.M. Monday-Frida
y.arrangements can be made for Saturday.o Holidays n Sundays,
telephone for acceptance of remains is necessary. *
earragements by
2. Pine View Crematorium is located on the grounds of the
View Cemetery, Quaker Road, Town of Queensbury. Pine
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
remains and to direct the disposition of of the
that any personal the cremated remains,
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 container Caskets and or suitable alternate
. containers must be of combustible
material . No Styrofoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be
on the authorization to cremate form before the remains willanswered
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 $100. 00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100. 00 Any remains received after 3:30
P-M. Mon-Fri or Saturday will be charged an additional $100. 00.