Drake, Marium TO rM/N OF QUEEN,,5BUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4.476 (518) 745.4-477
Funeral Director ` A
a-e MIIV\2t UM Case;;
Uf Cremation 2 --7 ZOG�
Cremation Started l �, -\-j
' . ' e Cremation Completed 0 ��
' pe of Containertia�ty -
:Turks
TOWN OF C>UEEN88URY |
PINE VIEW CEMETERY �
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CREMATORIUM `
Quaker Road, (Jueanmbury. New York 128O4 �
Phone (518) Crematorium 745-4477 (if no answer)
Cemebery745-447G
AUTHORIZATION TO CREMATE '
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The undersigned requests and authorizes Pine View Crematorium, in accordance with a,bd subject
to its Rules and Regulations no cremate the remains of-,
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MARIUM E. DRAKE FEMALE �
5 Spriice Street Lake Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 15th day of December 04
atFletcher—Annal Hospital, Biirlington, VT.
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
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Allan Drake, 5 Spriice Street, Lake Placid, NY 12946
�Relationship hzdeceased_
Name ofFuneral Home M. B. Clark, Inc. id, NY
12946
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IMPORTANT �
| napreson<thsthzthobeetofmyknnw\edgo. thadaceoaedhaso uomakerin�hksnrher
body. (CIRCLE ONE) |'
I certify that I have the full power and authorization to arrange for the cremation of the rE'irr�ins and
to direct the disposition of the cremated remains, that any personal possessions have e,',,'thbr been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Viia,,W.
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 as directed,Whether
such claims or demands are or are not wholly groundless, false or fraudulent.
27 Saranac Ave. , Lake Placid, NY 12946
(WITNESS) (ADDRESS)
5 Spriice St . , Lake Placid, NY 12946
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(SIGNATURE OF RELATIVE OR LEGAL REP, AND ADDRESS)
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Signed on this dat � Dec 20 3004 1
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DISPOSITION OF CREMATED REMAINS
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\ herebydirect Pine\�ew {�renn�tohurnhodiaposeofthecnyn�atedren�ansaoh��vxe:
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Mail to m. B. Clark, Inc. , 27 Saranac Aveniie
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Other arrangements-please peony
if pulverization cf cremated remains |s requested, check here__���_- `. .
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POLICIES, RULES AND REGULATIONS
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1 The crematorium will
w�dday-
Fhday. No Holidays or Sundays, arrangements can be made for Saturday. Preorrahgaments
by telephone for acceptance of remains isneceasory.' �|
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quakie' rRoad,
Town ofOueenabury �i
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3. An authorization for cremation properly signed by the nearest next oi kin other
person stating o�ingth�t�heydohave �hepo�erandouthor\tytoornonge�or[��cnam� /e
remains personal possessions
defend d
Sjvo
''~'- -either
ir� \� Crematorium as
harmless Pine ".
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which may be made against them Uy reason of orconneotadwUhthe cremation of
�ajd
remains and /or disposition of said remains as directed, whether such claims or de�n6nds are,
or are not wholly groundless, false orfraudulent. This authorization iD addition boa�re0u|ar
burial permit must accompany the remains.
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4 /U| remains rnuntbe encased ina casket orouhab|e alternate container. Caskets �
containers must be of combustible material. No Styrofoam or plastic containers vvoj'be
accepted.
5. The question relative to cardiac pacemakers must be answered on the authoriZ2tiqhto
cremate form before the remains will be accepted. �
G Un�saother a�angementsare nnadethe cremated remains m/iUben1ai\eU via Registered
� U.S. Mail within three days of cremation to the funeral home handling the Sen/<oa. ]'here will
bea $20.OU charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$225,00 Children (age 13lmonthsho
12 years) $115-0O Infants (stillborn bn12 months) $75.DO
° Additional $50.00 charge for cremations done after 100 P.M. Monday through Fridai' .
Cremations done on Saturdays will ba charged the additional $5U.00. '!
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