Boula, Joseph TOWN OF QUEEM
B U-r�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAXER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4.476 (518) 745.4,477
Funeral Director /41
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E Cremation
' .-e Cremation Started
' . -e Cremation Completed 1 J �
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' DISPOSITION QF CREMATED REMAINS
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i hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to M )
|f pulverization of cremated remains ie requested, check here_}[X__
POLICIES, RULES AND REGULATIONS '
1 The crematorium will be open for cremahonS 5 days a week 7-O0A.KX. - 3:3O P.M, k�ondey- ts
� Friday. NVHo|idaysorSundays. aangenn�ntsconbemadafor�atu/day� Pna�/ra�g�rnan
by telephone for acceptance of remains isnecaasary.'
2 `9\n�V\8vV �re[n��oriumiS \�C8tedon the grounds of the Pine VicvYCemetery, Quaker Road,
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Town of{3ueonsbUry �
o �zd
3 Anau1huhza1ionforuremaUonpnoper|ysignedby �hene�restnextofkiOorothora rzec
forUhecnem � �
a '"' �""'~''�~--' �-�t)e dohav .epo�erandauthordytoarnange � m.. .
persona��»Qtnsameyrema c otednemain�. that �ersonalp�sseesio»s
inaand �odireot�h� disposidonoftheorern defend and
have either been removed or may be destroyed and agree to protect,
and all claims and demands for loss or damages
harmle,ss Pine View Crematorium from any
which may oe made against "them ~y reason of
or connected with the cremation of�aid
directed, vvhethersuch o\air0oorde�n�»gsare,
ronnoin� �Dd /ordispoaihonofaa\dnennninsostnsh\s -uthoAz��|0nin �dditiun �o �regU|ar
o[ an8notvVhoUyQrouDd|eso. fa\Seor ��u�u|8n � | a
burial permit must accompany the remains. i
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4 All remains must be encased ina casket Or suitable alternate container, CaoketsaP��
containers must be of�ombuatible material. No Styrofoam or plastic containers
accepted.
5 Theque��onre|at�ehooerdiaopaoynnakeramustbe answered on the oudhohzat�hto
cremate form before the remains will be acceplso
G Unless other arrangements are made the cremated remains will be mailed via Registered
S Mil tO the funeral h0r0ehond8ngthe service. /|ne/e vviU
- -b ' $2D.OUuhargaforthissomice.
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Cremation Adn�ni�tna�onCossondRecordingFee: Adu|t$22S.D0 Children (age 13�)onhsto
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12yaaro Administration
infants (stillborn to 12 months) $75,00 �
° Additional $5O8O charge for cnemmdonadone after 3:OOp.K8. KAondoy through FhdaY.
{�nennahonsdon' on Saturdays will be charged the additional $5U.00. �
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TOWN OF (JUEENGBURY �
PINE VIEW CEMETERY �
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CREMATORIUM
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Quaker Road. Oueanobury, Now York 12804 '
Phone (518) Cr8o7ahnhWnl 745-4477 (if answer)
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CemeAery745-4478
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AUTHORIZATION TO CREMATE
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The undersigned requests and authorizes Pine View Coemahzhum, in accordance with d oubject
to its Rules and Regulations to cremate the remains of:
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Joseph R. Boii1a Male
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 9th day of Janiiary
at— AMC @ Saranac Lake
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Joanne MacDowell Breezy Acres, Saranac Lake. MY 12983-!
76 Briinswick Road, Saranac Lake, NY 12983
Relationship to deceased
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Name of Funeral Home yY 8 Clark, Inc 27 Saranac Ave, Lake pi,'l;i r-i ri
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8 IMPORTANT
| represent that to the best ofmy knnw|edgn, the deceased has orhas no pacemaker in isl or her
body. (CIRCLE ONE)
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I certify that I have the full power and authorization to arrange for the cremation of the rqm6ins and
to direct the disposition of the cremated remains, that any personal possessions have el,thbr been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Vi"aW
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,iwhether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) NY 124813
Signed on this date: Jan., 10, 2005
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