McKeown, Lawane rl-O WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/ Funeral Director /, i t�
Name 1�gh?}h& d aKAL4�1� Case # 3L4 1p
Date of Cremation 17 — 2 2 — moo q
Time Cremation Started R 'S-0 w til
Time Cremation Completed A-3
Type of Containerl411��„v�!
Remarks :
to
14
i
i
s
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: check here
If pulverization of cremate remains is req
uested,
POLICIES, RULES AND gEGJLATIONS
en for cremations 5 days a week ys,
1. The crematorium wi00
ll be open No Holidays or Sundaays
A.M. - 3:30 P.M. Monday-Friday.or Saturday. pre-arrangements by
arrangements c e made f
is necessary.*
telephone for acceptance
a P of remains rounds of the Pine
2, Pine View Crematorium Road, Town
oocated on the of Queensbury 9
View Cemetery, Quaker
signed by the nearest
person stating that they do have
3. An authorization for cremation properly for the cremation of the
next of kin or other authorized range
the power and authority I
remains and to direct the disposition eitherf been removed ormay be
rem possession have
that any personal p defend and save harmless Pine View
destroyed and agree to protect,
loss Of
Crematorium from any and all claims and reason demands
of or r connected
damages which may be made against them by
or are
with the cremation of said remainsla m/or de ands are,osition of sai
wi whether such c
remains as directed, false or fraudulent. This authorization in
not wholly groundless, permit must accompany the remains.
addition to a regular burial
4, All remae alternate
ins must be encased in a casket
orbeulofblaoT�ustible
ntain I
container. Caskets and co accepted.
material. No Styrofoam or plastic containers will be accep
relative to cardiac pacemakers must be answered
5. The question r
' te form before the remains will be
on the au
thorization to crema
accepted.
ated remains will
6. Unl
ess other arrangements are made ,nh the
days of cremation
be mailed via Registered
handling. thelservice. There will be a $25.00
to the funeral
charge for this service.
Costs an .00
d Recording Fee: Adult $300(stillborn
Cremation, Administration 13 months to 12 years) $150.00 Infants
Children (age
to 12 months) $100.00
* 'tional $100.00 charge for cremations done after 3:w 11 P.M.
Addi Cremations done on Saturdays ter 3:30
Monday through Friday. remains received of
charged the additional will 0 charged ed an additional $100.00.
P,M. Mon-Fri or Saturday will be charg
i
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745A477(if no answer)
Cemetery 745A4.76
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:
Lawane May McKeown Female .
(NAME) t (SEX)
Moses-Ludington Nursing Home, 1019 Wicker St. , Ticonderoga, NY 12883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 2 5 t h day of July 2004
at Moses-Ludington Hospital, - Ticonderoga, New York 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home Wilcox & Regan Funeral -Home, 11 Al onkin St.
Ticonderoga, New York 12883
IMPORTANT
1 represent that to the best of my knowledge,the deceased has or as n pacemaker in his or her
body. (CIRCLE ONE)
1 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
L-ematorium 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.
(WITNESS) (ADDRESS)
(SIGNATURE OF AE1ATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: