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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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TOWN OF QUtENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
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
(NAME) t t (SEX)
(STRE (CITY) ATE) (ZIP CODE)
who died on day of //%� �' 20 m3
1171 -L 4�-,,�
s .may
(PLACE) (ADDRESS)
Name and address of nearest liming relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
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
..6;rnatorium 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 clai or demauds are not wholly groundless,false or fraudulent.
Ala
-(WITNESS) DRESS)
SIGNATUR OF LA E OR LEGAL REP.AND ADDR SS)
�O �t
Signed on this date:_ D
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 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 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 or suitable alternate
container. Caskets and 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 cremate form before the remains will be
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.
My DLhyery
(Required by Section 414 5 - NYS Public Health Law)
........
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A. NAME OF DECEASED PERSON: ,I i J 4, 2 5- �,! L, ILI _
(as it appears on burial,cremation or transit permit)
B. DATE THAT BODY WAS DELIVERED:
C. NAME AND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAKING 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:
(Npnie) (city,state)
/1MG14AWAf Pffnerafthrwtor) (SI TME of Person Receiving Body)
V,7�ti�Copy-Funeral Director Yellow Copy-Place of Final Disposition Blue Copy-Decedent's Family