Kingston, Patricia OF QUEEN
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
vFuneral Director
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Remarks
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DISPOSITION OF CREMATED REMAINS
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I �ere v direct Pine View Crematorium to dispose of the cremated remains as follows:
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ail to M. B. Clark, Inc.
27 Saranac Ave. , Lake Placid NY 12945
Cher arrangements-please specify:
I !pulverization of cremated remains is requested, check here xx
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II 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
j� 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
haveeither 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.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
�l accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
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 ,iemation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
19 years)`$150.00 Infants (stillborn to 12 months) $100.00
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dditloha! $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
C ematioris done on Saturdays will be charged the additional $50,00.
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium/ 5-44787 (if no answer;)
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Cemetery
. AUTHORIZATION TO CREMATE
tie undersigned
requests and authorizes Pine View Crematorium in accordance with and subject
o its Rules and Regulations to cremate the remains of.
Patricia (SEX)
(NAME)
I, �1 1 Cascade Rd. Lake
` 0 (CITY) (STATE) (ZlP CODE)
(STREET)
)who died on 4th day of 0
`Cascade Acres #34 Lake Placid NY 12946 _--------
'gat (ADDRESS)
(PLACE)
Name land address of
nearest living relative or name of person authorizing cremation:
946
; Terrence K' n
Relationship to deceased Husband
Na
me; of Funeral Home M B Clark, Inc. , 27 Saranac Ave. Lake P1aNYd12946
IMPO..RTANT
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 sonaheossessiion o shave either her been of the remains d
to dirbct the disposition of the cremated remains, that any p P
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 claims or demands are or are not wholly groundless, false or fraudulent.
l 1 27 Saranac Ave. , Lake Placid, NY 12946
(WITNESS) (ADDRESS)
��� �,,� Cascade Acres #34, Lake Placid,
- NY 12946
(SIGNATURE OF RELATIVE R LEGAL REP, AND ADDRESS}
6, 2003
signied on this date:-T Oct.