Blanchard, Harold II TO gtiQ OF QUEE9�5BUP�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ej I&
Cases -5 '3
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Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary.Prearrangernents are
necessary for Saturday cremations.
2. A 'Authorization for Cremation'signed by the nearest next of kin is necessary 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 Cemetery and 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 cWected,whether
such claims are, or are rat wholly groundless,false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate corgi.Caskets and comers
must be of a combustible material. No styrofoam or plastic containers wi71 be accepted.
4. Cardiac pacemakers,defibrMators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within ttxee working days(72 hours)of receipt of the
B4rial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U. S. Maid within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a$25.00 charge
'for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $300.00
Children (age 13 months to 12 years) $150.00
Infants (stillborn to 12 months) $100.00
Overtime Cremations(Weekdays) $400.00
Saturday Cremations $400.00
3
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: 518-745-4476, Crematorium: 518-745-4477
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:
HAROLD E . BLANCHARD-;V- MALE
(Name) (Sex)
105 LOWER FEEDER ST . , HUDSON FALLS , NY. 12839
(Street) (City) (State) (Zip Code)
who died on 8TH dayof DECEMBER 20O4
atKING HENDRICK MOTEL , 1602 RTE . 9 , LAKE GEORGE NY. 12845
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
DANA BLANCHARD , 5641 COUNTY RTE . 30 , GRANVILLE , NY. 12832
(Name) (Address)
Relationship to the deceased BROTHER
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(hass not paoemalcer.delilbrillator or any other battery operated
device in his or her body. (Circle One)
I certify that i have full power and authorb ation 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 daims and demands for loss or dwmpes which may be made age'snst dmn
by reason of or connected with the cremation of said remains as directed,whedier such claims or demands are or are not wholly
groundless,false or fraudulent.
0 Box 277 , FORT ANN , NY. 12827
("►ness) SAME AS
( )
(Signature and Address of Relative or Legal R ABOVE
Signed on this date: � � //'2"'e'�
Disposition of Cremated Remains
hereby direct Pine View Crernallorimn to dispose of the cremated remains as follows:
Mal to
Other arrangements-Please specify:
If puhremmtion of cremated remains is requested,deck here
Revision:July 7,2004