Lucia, Carolyn TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ✓4 yA S �Z
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Date of Cremation CUO
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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: Return to Funeral Director
If pulverization of cremated remains is requested, check here X
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 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 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 (stillbom to 12 months)$100.00
* Additional$50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional$50.00.
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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:
Carolyn Lucia Female
(NAME) (SEX)
PO Box 120, 375 Athol Road, Athol, New York 12810
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 23rd day of June 20 04
at Her Residence; 375 Athol Road, Athol, New York 12810
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
William Lucia, PO Box 120, 375 Athol Raad, Athol, New York 12810
Relationship to deceased Husband
Name of Funeral Home Alexander-Baker Funeral Home, Warrensburg, NY 12885
IMPORTANT
I represent that to the best of my knowledge, the deceased3iffM has no pacemaker in Ma 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
Crematodu any and all claims and demands for loss or damages which may be made
against m reason of or connected with the cremation of said remains as directed,whether
such ai r demands are or are not wholly groundless, false or fraudulent.
John S. Alexander, 3809 Main St Warrensburg, NY 12885
717 NESS) (ADDRESS)
William Lucia, PO Box 120, 375 Athol Rd, Athol, NY 12810
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: June 23, 2004