Massian, Lydia TOqAIN OF QUEEN
,5BUP�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
11 Funeral Director /NA �)
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DISPOSITION OF CM LTED
I hereby direct Pine View Cremato ,um to dispose of the cremated
remains as follows:
Mail to M B Clark, Inc.
d, Iry 1.2946
Other arrangements - please specIty. witt=Vick-40=4i/la/04
If pulverization of cremate remains is requested,, check here J
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-arrangement., 2y
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 "t`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.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road
Phone(518) , Queensbury, New York 12804
Crematorium 74 5-4477(if no answer)
Cemetery 745-44.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
to its Rules and Regulations to cremate the remains of
accordance with and subject
L dia A. Massian
(NAME)
420 Old t (SEX)
Militar Rd. Lake Placid
(STREED (CITY) , NY 12946
(STATE) (ZIP CODE)
Who died on 12 t h
day of December
2004
at [Jihlein Merc Center,
{PLACE) Old Militar Rd. , Lake placid.
(ADDRESS) NY 12946
Name and address of nearest riving Dawn J e r o b e t z '7 g relative or name of person a uthonzing cremation:
Clintonville Rd: , Pere, NY12972
Relationship to deceased Dail hter-
In-Law
Name of Funeral Home M B Cl ark Inc.
27 Saranac Ave.
IMPORTANT d, NY 12946
1 represent that to the best of my knowledge, the deceased as
body. (CIRCLE ONE) �- as vlPacemaker in his or her
1 certify that I have the full power and authorization to direct the disposition of the cremated remains, to arrange for the
removed or may g cremation of the remains and
Y be destroyed,and agree to rot y personal possessions have either been
;�matorium from any and all claims and demandsp 'defend and save harmleSs Pine V ew
'against them by reason of or h theafor loss or damages which ma
such claims or demands are or are not connected
the cremation of said remains as directed made
� Y groundless, false or fraudulent ,whether
27 Saranac Ave.
(WITNESS) (ADDRESS) Lake Placid, NY 12946
2el-GQNA�T OF ELA E OR L ��� ���'� vi�fc , �°
EP•AND ADDRESS)
Signed on this date: Dec. 12, 2004