Lee, Virginia EEM
( rn(-J/I/)N OF QU s5BUU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
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DISPOSITION OF CREMATED REMAINS
| hanebydirect PineVl�NCrennatohurntodiapose0fthec[an�atednonlainsasfdbvvo �
Mail to j
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27 Saranac Ave- r Lake Placid, NY 1294f,—
Other arrangements-please specify:
if pulverization of cremated remains ha requested, check here xx__
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POLICIES, RULES AND REGULATONS ^
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1 The r�nlatohummxUbe open for crema� days sawaek7�D0/�KX� - 3:38p.K4. w�dday'
ec NoHo|i�aysor8und�yS. arnangen�ents nbonlode for Saturday, Preornahgprnenta
Fri
day. t fnamainsisnaoeasery ' '
byte|ephoneforaooapenroo � !�
���� �nthegn�Vn�sof�ePinuVim0Cem�e�. Qu@kerROad.
2. P|neV|ewCnematohumis \
Town nfOueensbury �|
3 Anoutkoriza�onfor �renneUonpropedy �ignmdby1henearestnextofkinorodhera br�ed
sbtingthattheydohavethepowerandouthoritytoernang�forUl* c �c@ the
.
personi e �nd �nd\rectth� disposihnnnf\hacrennotednemaina. thetony pereonolp�psosem
remaiprons defend d sove
whichhave either been removed or may be destroyed and agree
harmless Pine View Crematorium from any and all claims and demands for loss or(�a m� ayet>
^ � may be made d /or disposition of said remains as U/recteo, whether such claim s ". d.~...._- are,
ainst them by reason of or connected with the cremation of�sald
— are '
ren�emso» o� groundless, false urfraudulent. This authorization inadditioOho8,regV|ar
remains.
burial permit nnuetaccompany the
or suitable alternate container, Caskets and
4. All remains must be encased in a casket
containers must be of combustible material. No Styrofoam or plastic containers wilt be
nswered on the authorizatic, to
5. The question relative to cardiac pacemakers must be a
cremate form be-fore the remains will be accepted.
are made the cremated remains will be mailed via Registored
6. Unless other arrangements
U.S, Mail within three days of cremation to the funeral home handling the service. Th:ere will
be a
00 charge for this service.
' 5 OO Children (age 13��onMhsto
Cremation, Administration Cos sand Recording Fee: Adult � nsn ` . �
' 15OO \ (stillborn to �
12yearg) �1 � Infants (e n n � �
° Additional $50.00 charge for cremations done after 3:00 P.M, Monday through Friday. .
Cremations done on Saturdays
viUbechorgadtheadditiono\ $5O-DO. �
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TOWN OF QUEENSBURY I ;
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with arid, subject
to its Rules and Regulations to cremate the remains of:
VIRGINIA A. LEE Female
(NAME) (SEX)
89 Greenwood Street, Lake Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE)
i
who died on 24th day of January i1 2005
at Adrk Medical Center Saranac Lake, NY 12983
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
Barbara R'_ Lee 89 Greenwood St. , Lake Placid, NY
Relationship to deceased Sister
Name of Funeral Home M B Clark, Inc. , 27 Saranac ave. , Lake�id,
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 rginnains and
to direct the disposition of the cremated remains, that any personal possessions have ether been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Vi0aW
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 cla',s or demands are or are not wholly groundless, false or fraudulent.
27 Saranac Ave. , Lake Pl ari d,_MY ;i?qa fi_
(WITNESS) (ADDRES
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' 89 eenwo St. , Lake IA 4 ; Placid„
(SIGNATURE OF RELDATIVE O EGAL REP. AND ADDRE ) 12946
Signed on this date: Jan. 24, 2005 ?
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