Kallit, Lydia rrO`KN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-
Name- —V�ti L4 { 1, 1 Case # 'A Ce- (1)
Date of Cremation. 16 t � _ 2C/o LA
Time Cremation Started 14/l.
Time Cremation Completed
Type of Container
Remarks :
l;
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the c--emate
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 4ee -
7 :(a0 A. M. — 3:30 P. M. Monday—Friday. No Holidays or 5.:naays ,
arrangements can be made for Saturday. Prearrangements 21
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the � ; ne
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 oo 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 -e
destroyed and agree to protect , defend and save harmless p : ^ e
View Crematorium from any and all claims and demands for loss 0 '
damages which may be made against them by reason of or connecter
with the cremation of said remains and/or disposition of sa : r
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent . This authorizet : - -
in addition to a regular burial permit must accompany t ^ e
remains.
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combust : r : e
,material . Nc styrafoam or plastic containers will be acceptez .
5. The question relative to cardiac pacemakers must be answer-er
on the authorization to cremate form before the remains " : I ) _e
accepted.
6. Unless c :her arrangements are made the cremated remai - s
oe mailed vic Registered U. S. Mail within three days of ere ^,at : t -
- o the funerz, ! home handling the service. There will be a
charge for tr : s service.
Cremation, Aclinistration Costs and Recording Fee . Adult s175. 1,
Children (ac � 13 months to 12 years) s100. 00 Infants -
t 0 12 months ) $60. 00
TOWN OF DUEENSBURY F�
PINE VIEW CEMETERY
i
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Lydia Kallit Female
(Name) (Sex)
49 Sagamore St. , Glens Falls, NY 12801
(Street ) (City) (State) (Zip Code )
Who died on 16th day of Oct
4* 04
at Eden Park NH, Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or nave of pe.-scm
authorizing cremation :
Victor Kallit, 6844 SE Warwick Lane Stuart FL 34997
(Nave ) (Address)
Relationship to the deceased Son
Name of Funeral Home Alexander-Baker, Warrensburg
IMPORTANT:
I represent that to the best of ray knowledge, the deceased *UaDoot
nas no 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
been removed or ma been have e : zr,er
y be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all c '. aims
and demands for loss or damages which may be made against there by
reason of or connected with the cremation of said remains as
directe whether such claims or demands are or are not wnol ,
grou leis, false or fraudulent .
Warrensburg, NY
itness ) (Address)
Same as above
( : 90atu a of Relative or Legal Re -
9 p. and Address )
' : gned on this date ; 8-3-04