Patnode, Luke r-roWN OF QUEEN5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funer Director L �� C 1R
Name �• UK1, , Lt � h/ � Case# 3 (*J
Date Of Cremation r7 _
Time Cremation Started l a > Y'-4
Time Cremation Completed
Type of Container (,L��
Remarks
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TOWN OF QUEENSBUR.Y
j PINE VIEW CEMETERY
I
CREMATORIUM
Quaker Road, Queensbury• New York 12804
Phone (518) Crematorium 745-4477 (if no answer!
i Cemetery 745-4476
1 AUTHORIZATION TO CREMATE
lie undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
o its Rules and Regulations to cremate the remains af.
Luke L. Patnode Male
(SEX)
(NAME)
�I 1 Hillside Road #22 Lake Placid, NY 1
' (STREET) (CITY) (STAY!^) (Zip CODE)
! 2Q03
hd died on 6th day
of Jtxl
Adrk Medical Center, Saranac Lake, NY ----------
at
(ADDRESS)
(PLACE)
Name land address of nearest living relative or name of person authorizing cremation:
i Therese
Patnode 1 Hillside Road, Lake Placid, NY 12946
Relationship to deceased
4Jife
Name of Funeral Home M B Clark Inc._,,_
27 Saran NY 12946
11
IMPORTANT knowledge, the deceased has or has no pacemaker in his or her
1 represent that to the best of my g
body,: (CIRCLE ONE)
I certify that I have the full power and authorization to
any persona arrange for l possessions have either beenion of the remains
to dirbct the disposition of the cremated remain
ew
removed or may be destroyed, and claims aree to protect, defend and save harmless nd demands for loss or damages which many be made
Crematorium from any and allins
against.them by reason of or connected with wholly t e cremation
re ationfolse or remafraud tents directed, whether
• such clai s ar demands are or are Y
p� ac Ave. , Lake Placid, NY 12946
27 Saran
(WITNESS) (ADDRESS)
�--` � ,/ 1 Hillside Road, Lake Placid,
(SIGNATURE OF RELATIVE OR LEGAL RCP. AND AD
DRESS)
7/07/03
Signed on this date: 0
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DISPOSITION OF CREMATED REMAINS
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I hereby!direct Pine View Crematorium to dispose of the cremated remains as follows:
ail to M B Clark, Inc. 27 Saranac AyP. , Lake placid, NY
' (ASAP)
Jtlher arrangements-please specify:
I !pulverization 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.
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
harm iess 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 /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.I All remains must be encased in a casket or suitable alternate container. Caskets and
k� containers must be of combustible material_ No Styrofoam or plastic containers will be
accepted.
5.� The question relative to cardiac pacemakers must be answered on the authorization to
I cremate form before the remains will be accepted.
6.1 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.
C rematiorl, Administration Costs and Recording Fee: Adult $300.00 Children (age 13 months to
1 ;years)'$150.00 Infants (stillborn to 12 months) $100.00
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dditiohal $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
C emationis done on Saturdays will be charged the additional $50,00.
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