Outcalt, Mindy To`WN OF QUEEN,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director - -
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_ace Of Cremation
Time Cremation Started sv IA: vn
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jemarks
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Bod.X Delivery Recei
(Required by Section 4145 - NYS Public Health Law)
A. NAME OF DECEASED PERSON: /—//A10/ D ,//4 L j
(as it appears on burial,cremation or transit permit)
B. DATE THAT BODY WAS DELIVERED: /UCH V,
C. NAME AND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAIGNG DELIVERY:
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(Print Name) (Reg. #)
D. NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral Firm Name)
E. NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSITION WHO RECEIVED THE BODY:
(Print Name)
CHECK (✓) IF NO ONE IN CHARGE
F. NAME/LOCATION OF PLACE OF FINAL DISPOSITION:
f'rti'C V11 vV t''iL,,/r�olCf!"��
(Name) (City,State)
(SIGNATURE of Funeral Director) (SIGNATURE of Person Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Blue Copy-Decedent's Family
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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:
M B Clark ail to Inc. , 27 Sar.an_an .�AvPn»e
NV 12946 -
I
ther arrangements-please specify:
ipulvediation
I of cremated remains is requested, check here xx
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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 Uiew 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
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 /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 re"rnains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
IIaccepted.
5.1 The question relative to cardiac pacemakers must be answered on the authorization to
I cremate form before the remains wiil be acuepied.
6.'I 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 ematioil, 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 ematioris done on Saturdays will be charged the additional $50.00.
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TOWN OF QUEENSBUR.Y
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12834
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
I AUTHORIZATION TO CREMATE
tie undersigned reaues is anum, in accordance with and subject
d authorizes Pine View Crematori
L ts Rules and Regulations to cremate the remains af.
Female
Mindy Ann oiztcalt (SEX)
II (NAME)
334 Hill Avenue Vardaman (STATE) (Zip CODE)
(STREET) (CITY)
17 th day of
Nov. 2�3
)who died on
N�. Mississi i Med. Ctr. ,Tiz elo, MS --------
i at ADDRESS)
3 ; (PLACE) (
Name land address of nearest living relative or name of person authorizing cremation.
Saranac Lake, NY
Relationship to deceased Father
Name of Funeral Nome M B Clark, Inc. , 27 Saranac Ave. , Lake Placid, NY
--- 12946
IMPORTANT
Las 4 represent that to the best of my knowledge, the deceased s or has no pacemaker in his or her
body.: (CIRCLE ONE)
-nation of the remains
I certify that I have the full power and authorization to arrange
for the crei
possessions have either beend
to direct the disposition of the cremated remains. that any personal
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.
y �� 27 Saranac Ave. , Lake Placid, NY 12946
(WITNESS) (ADDRESS) A
(S1 R- OF F RELATIVE - EGAL REP. AND ADDRESS)
Signed on this date:_ Nov. 18, 2003