Desabrais, John TOWN OF QUEE BUTy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director a `� �,S0N)
Cases
ace Of 'Cremation
=�^e Cremation Started_ if \
' ime Cremation Completed
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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 cremated 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-
Fricay. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements
by telephone fcr acceptance of remains is necessary..
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queer sbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
person stating ':hat 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 beE!n 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
w:ni--h 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
bur al 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 cays of cremation to the funeral home handling the service. There will
be a $20.00 charge for this service.
Cremat on, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 11ants (stillborn to 12 months) $75.00
k Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremat ons done on Saturdays will be charged the additional $50.00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
,AUTHORIZATION TO CREMATE
'-he undersigned -equests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
L7 yr ✓ �PS�df2/�i.S /�.4-(��
(NAME) (SEX)
(STREE?) (CITY) (STATE) (ZIP CODE)
,,vho died on _ 44— day of ✓ us e 20__
(PLACE) (ADDRESS)
Narre and address of nearest living relative or name of person authorizing cremation:
d14-9 6 Z19f-s r��o��r`s /7 t/e.-9 C 47 4AJ 14
Relat,onship to deceased
Name of Funereal Home 1-6c0crer� j-'�) rtite
IMPORTANT
I represent that to the bjest o- my knowledge, the deceased has or has no pacemaker in his or her
bode. (CIRCLE ONE)
I certify that I hEve the full power and authorization to arrange for the cremation of the remains and
to d rect the disposition of the cremated remains, that any personal possessions have either been
remDved or may be destrcyed, and agree to protect, defend and save harmless Pine View
Crematcriumn from any and all claims and demands for loss or damages which may be made
against them by -eeson 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.
(WITNESS) (ADDRESS)
(SIGNF -URE OF RELATIVE OR LEGAL A REP. AND ADDRESS)
Signed on this date: 0 iZd -f/12 Z I
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