Manning, Clark TOrWN OF QUEEN,50UP�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLJEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
orv��9��- �
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
G-P r,\-\ 6 NZ A KI A-
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
6
DISPOSITION OF CREMATED PM4AINS
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
rization
not wholly groundless,
regular burial permit must accompany the remains.
ore � false or nt. This ao in
addition to
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 cardiacto form before the mrema ins will rbe
ed
on the authorization to cremate
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered
handling.the Mail
service. three
Theredays
willobe cremation
$25.00
to the funeral home
charge for this service.
Cremation, Administration 13 months toyears)e $150 00 Rcording Fe Adult Infants (stillborn
-00
Children (age
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.
TOWN OF QUEENSBURY /'�
PINE VIEW CEMETERY
CREMATORIUM
a
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
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:
CLARK B . MANNING MAIF
(NAME) (SEX)
10566 STATE RTE . 149 , FORT ANN , NEw YnRK .12827
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 8THdayof DECEMBER 2003
at GLENS FALLS HOSPITAL , 100 PARK ST . , GLENS FALLS , NY. -12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
MR . JOHN MANNING , 2297 BARTRAM AVF _ , ATCO , NJ . 08004
Relationship to deceased S 0 N
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT
I represent that to the best of my knowledge, the deceased has has no p cemaker in his or her
body. (CIRCLE ONE)
1 certify that i have the full power and authorization to armage 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
G ematodum 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 la' or demands are or are not wholly groundless, false or fraudulent.
( �Z� 45W4-?' P - O - Rny ?ZZ . ET
Y. 12827
TN S) (ADDRESS)
✓� SAME AS ABOVE
SIGNAeTMR OF LATIVEON&GAL REP.AND ADDRESS)
Si on this date: