Aust, Martha "O UN OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
y�, Funeral Director n Ck- 1-1
Name a�/f/ � �l '�n-q T ip 9�l� �✓ Case # " Z�
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container h61�7j 0
Remarks : )
f7�Z-
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremat
remains as follows:
Mail to M B Clark, Inc. , 27 Saranac Avenue
Lake Placid, NY 12946
Other arrangements - please specify:
If pulverization of cremate remains is requested, check herexx
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00
A.M. - 3:30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.*
2. Pine View Crematorium is located on the grounds of the Pine
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 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
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 (stillborn
to 12 months) $100.00
* 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.
I
TOWN OF
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 w'
to its Rules and Regulations to cremate the remains of
rth and subject
( � Martha E. Aizst
•Female
89 Greenwood St. , Lake Placid, NY
(STREET) (C� 12946
(STATE) (ZIP CODE)
who died on 8 t h
day of November 20 04
(PLA )
at IJihlein Mercy Center la, e placid, NY 12946
CE (ADDRESS)
Name and address of nearest living relative or name of peen authorizing
Miss Donne Dillon aemation:
Relationship to deceased
Daughter .
Name of Funeral Home M B C i a r k, Inc. , 27
Saranac Ave. Lake Placid, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased�s or hRU0 Pacemaker in his or
body. (CIRCLE ONE) her
!certify that l have the foil Power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cxemated remains, that an removed or may bed Y Personal possessions have either been
;drieY destroyed,and agree to protect, defend and save harmless pine View
matorium from any and all Bairns and demands
against them by reason of Or connected with h cc matio�n Of damages which may be made
such claims or demands are or are not wholly groundless, false or fraudu nt directed,whether
l
(WITNESS) (ADDRESS) 6
-C�� 8 Greenwood St. , Lake Placid, NY 12946
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) Apt. 301
Signed on this date: Nov. 9, 2004