Kennedy, Betsy TORN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��
Name Case # 2-
T
Date of Cremation l f 5e)
Time Cremation Started
Time Cremation Completed
Type of Container R-7 4-1vu
Remarks :
Cc�ALU;0 L) M,0VIZ- ti �
641
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DISPOSITION OF CRF.MATF
I herebySINS
direct Pine View Crematorium to dispose of th
remains as follows:
e cremated
Mail to
Other arrangements - please s
If pulverization of cremate remains •is re
quested, check here_xx
POLICIES, RULES AND RELATIONS
A.M. - 3:30 P.M.The crematorium
. will be open for cremations 5 Monday-Friday. No days a week 7:00
arrangements can be made forSaturday. Sundays,
Holida s
telephone for acceptance of remai s is necessary.*y or Pre-arrangements by
2• Pine View Crematorium is located on
View Cemetery, Quaker Road, Town of the grounds of the Pine
Queensbury.
3. An authorization for cremation properly signed
next of kin or other authorized 9 by the nearest
the power and authority Person stating that they do have
remains and to Y to arrange for the cremation of
that an direct the disposition of the cremated remainse
Y personal possessions have either been removed or may be
destroyed and agree to protect, defend and save harmless
Crematorium from an ss Pine View
damages which may be madeagainst them claims and demands for loss of
With the cremation of said remains and/or dis osi
y reason of or connected
remains as directed, whether such claims or
not wholly
P tion of said
addition to rou dless, false burial or fraudulent. demands are, or are
This authorization in
permit must accompany the remains.
4 . All remains must be encased in a casket or suitabl
container. Caskets and containers must a alternate
material. No Styrofoam or plastic containers will be accepted.tible
5• The
on the authorization relative
crematerform pacemakers must be answered
accepted. before the remains will be
6. Unless other arrangements are made the cremated remains
be mailed via Registered U.S. Mail within three days of cre will
to the funeral home handling the service. There will be a oration
charge for this service. $25.00
Cremation, Administration Costs and RecordingFee.
Children (age 13 months to 12 years) $150. 0 Infants $300.00
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 An
P-M. Mon-Fri or Saturday will be charged an additional d $OOe 00.
�Z 7
TOWN OF QUEENSBURY
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:
BETSY N. KENNEDY FEMALE
(NAME) % I (SEX)
Harbor Condominiums # 18 Lake Placid, NY 1.2_946
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 28th day of November 20_Q�L_
Harbor Condominiums #18 Lake Placid, NY 12946
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Jade M. Kennedy 2108 Peterborough' Ln.; Charloytte, NC 28270
Relationship to deceased Son
Nameof 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 or has 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 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 as directed,whether
such claims or demands are or are not wholly groundless,false or fraudulent.
27 Saranac Ave. , Lake Placid NY 129 6
(WITNESS (ADDRESS)
---7 _1 � ? 08 Peterborough Ln.;, Charlotte, NC
(SIGNA UR F RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: