Payton, Joseph 4 -
OF QUEEN5BU-'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name � ���. � ph:y-+O'rl Case;
Dace Of Cremation
Time Cremation Started %qS 1,y1
Time Cremation Completed ,g&
Type of Container Wood
Remarks
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TOWN OF QUEENSBUR.Y
PINE VIEW CEMETERY
CREMATORIUM
i
Quaker Road, Oueensbury. New York 12804
phone (518) Crematorium 745-4477 (if no answer?
Cemetery 745-4476
AUTHORIZATION TO CREMATE
I
he undersigned requests and authorizes P em ins ocfrematonum in accordance with and subject
o its Rdies and Regulations to cremate the
Male
JOSEPH H. PAYTON (SEX)
(NAME)
ltll$ AVERYVILLE Road, Lake Placid, NY 12946
(S EET) (CITY)
(STATE) (ZlP CODE)
June 202p03
11 th day of
ho di;d on
1146 Averyville Rd• ,
Lake Placid, NY - ----�
at (ADDRESS)
l (PLACE)
Y `
I{ ! cremation:
.. Namejand address of nearest living relative or name of person authorizing
1 146 Averyville Rd. , Lake Placid
l Joseph Payton
Relationship to deceased
Son
+�. ;:. Clam, 111C.
rr Barone♦�w
Name,of Funeral Nome � PUNK xy.um
IMPORTANT
re resent that to the best of my knowledge, the deceased has o has n pacemaker in his or her
1 body. (CIRCLE ONE)
power and authorization to arrange for the crematoo s f the remains have ether been
I certify that I have the full p personal passessi
1l to direct the disposition of the cremated remains,that any p
ew
es which may be made
remoued or may be destroyed,c`anms aagree
nd demands for eloss or damafend and ges
which Pine ma
Crematorium from any and all
agair st them by reason of or connected with theoundless, fa se or fraudulent directed, whether
swch clai r demands are or are notwh Y 9 Lake Placid, NY
27 Saranac Ave. ,
4 MESS) (ADOR S
Averyville Rd. , Lake Placid
S NA,T RE OF RELATI EGAL REP. AND ADDRESS)
Jizne ill, 003
Sign, on this date:_
DISPOSITION OF CREMATED REMAINS
I �hereby�direct Pine View Crematorium to dispose of the cremated remains as folfows:
ail to
7 ko 2 'artanc Ave.
?.AW MA-0d, N—Y. 121-ff AsAP
Jtheri arrangements-please specify:
I f pulveriiation of cremated remains is requested, check here x,,"
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.
31 An authorization for cremation properly signed by the nearest next of kin or other authorized
persp:n stating that they do have the power and authority to arrange for the cremation of the
rema'ins 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 for 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
4.1 All remains must be encased in a casket or WA11VIa"riAte container. Caskets and
IIcontainers must be of combustible rnater@l`IJAy%*bWmffbv,1pIastic containers will be
accepted.
. 1
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
6. Unle4is 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.
Ci mation, Administration Costs and Recording Fee: Adult $300-00 Children (age 13 months to
I . ;
1 years)'$150.00 Infants (stillborn to 12 months) $100.00
ii
!dditional $50.00 charge for cremations done after 100 P.M. Monday through Friday.
Cielmation!s done on Saturdays will be charged the additional $50.00.