Tiffany, Violet r'-O`J4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director—
Name- t�- yto IPF�e7 I � � _Case # 3g a
Date of Cremation —a^ G�
Time Cremation Started Il d M
Time Cremation Completed a • 10 PP)
Type of Container
Remarks :
M < ,�
i : 5� Pry
uU Pr'1
DISPOSITION OF CREMATED SINS
I hereby direct Pine View cremated
Crematorium to dispose of the
remains as follows: ated
Mail to M B Clark, Inc.
Other arrangements - please specify: 1294
If pulverization of cremate remains is requested, check here xx
POLICIES, RULES AND REGUL&TIONS
1. The crematoriumwill be open for cremations 5 days a week 7:00
A.M. 3:30 P.M. Monday-Friday.
o Holidays or Sundays,
arrangements can be made for aturda
telephone for acceptance of remains is necessary.*
arrangements by
2. Pine View Crematorium is located on the grounds of th
View Cemetery, Quaker Road, Town of Queensbury, a Pine
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
remains and to direct the disposition of of the
that any personal the cremated remains,
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
to 12 months) $100. 00 (stillborn
* 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
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:
Violet'D. Tiffany Female.
(NAME) (SEX)
420 Old Military Road, Lake Placid, NY 12946
(STREET) - (CITY) (STATE) (ZIP CODE)
who died on 2 8 th day of Jiz 1 y 004
at I7ihlein Mercy Center, Lake Placid, NY 12946
(PLACE) (ADDRESS)
Name and address of nearest Irving relative or name of person authorizing cremation:
Mrs. Diane Cardinale 44 Chi monk Lane. , Lake Placid,
NY 12947
Relationship to deceased Da a gh t e r
Name of Funeral Home M B Clark, Inc. , 27 Saranac Ave. , Lake Placid, NY
12946
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as n 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
.G`rematorium 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,
Cie.<<=t-/I• 27 Saranac!
Ave. T akP P1 a i rl NY 12946
(WITNESS) (ADDRESS)
h�l �,n� 44 Chipmonk Lane, Lake Placid,j
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) NY 12946
Signed on this date: ` L d