MacKay, Dorothy 1'
rrorMIN OF , QU E E 5BUTY
V
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director �'�.{ CIgf
cl(, Casea 3 �
.a : e Of Cremation I /a L �o
' :-e Cremation Started $ 4b /} d _
' :-e Cremation Completed �� � /� �` �
oe of Container C,11Ci C",. d Ff .
. :arkS
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� o ; 3 ° 401 .
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mailto M B Clark, Inc. , 27 Saranac Ave.
Lake Placid, NY 12946
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here xx
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 4uthorizctjon for cremation properly signed by the nearest next of kin or other authorized
on stating that they do have the power and authority to arrange for the cremation of the
perains 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 agi/or disposition of said remains as directed, whether such claims or demands are,
or are not ftolly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must aQcompany 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.
3
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.
r
Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $1500 Infants (Fatillborn to 12 months) $100.00
* Additional $ 06 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done oiT Saturdays will be charged the additional $50.00.
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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 and subject
to its Rules and Regulations to cremate the remains of:
DOROTHY MACKAY Female
(NAME) ; i (SEX)
30 Greenwood St . , Lake Placid, NY 12946 i
(STREET) (CITY) (STATE) (ZIP CODE) }
who died on 23rd day of Jan. 20 5
at tJihlain Mercy Center 420 Old Military Rd. , Lake Placid
(PLACE) (ADDRESS) ""'`' rxlk
4
Name and address of nearest living relative or name of person authorizing cremation:
:rtr; .fir.,
Mrs Ruth Senecal
r of
�t ^�3�,}ICrTI1r;a
s;ti 3 ri.1 t�
Relationship to deceased Sister
Name of Funeral Home M B Clark, Inc. 27 Saranac Ave. , Lake Placid,
3 . i
IMPORTANT
represent that to the best of my knowledge, the deceased has o 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
su claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
30 Greenwood St.;, Lake Placid, NY 12946
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: July 17, 2002
TOWN OF QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -D e. /y((j i-Z L
Name A& N F'0-7 4
- � Case# l
Date Of Cremation l _ 2 d- 77-00 j
Time Cremation Started ,tj''S lc1 —A.—N
Time Cremation Completed
Type of Container 0tgR-d (jays Z t.l
Remarks
2 d45 AA V
10
. TOWN OF OUEENSBURY
PINE VIEW CEMETERY
d
CREMATORIUM
Quaker Roac, Queensoury, New YOrK 12a04
Phone (51B)Crematorium 745-4477 (if no answer)
Cemetery 745-4479
AUTHORIZATION TO CREMATE
The undersignea requests and authorizes Pine view Crematorium in accordance wiln anc suoiect
to its Rules and Reguletfvns to cremate the remains of;
S 4(NAM
lsEx1
(S EET) (CITY) I (STATE) (ZIP CODE)
t�
who died an y�� day of /so ,20 O
at r N 1
(PLACE (ADDRESS)
T /
Name and address of nearest living relative or narna of person authorizing cremation
re o- r 2A
r,
r
RelAtionship to dect!eead�,"
1
Name of Funefal Home
IMPORTANT
I represent that to the beat of my knowledge, the deceased pig o rid eti rid pacemaker in nt7 or ner
body. (CIRCLE ONE)
oertlfy that I hove the full power and eulhorizalion to arrange for the cremation of the remains ano
to direct the disposition of the cremated remalns. Chet any personal possesslons nave either Deem
removed or may be destroyed, and agree to protect. Oafeno ana lave nermiess Pine view
Crematorium from any and ell Claims and demands for losb or damages which may oe,mooe
against them by reason of or connected with the cremation of said remains as directed, wnetner
sueh algil'imLor de ride We or are not wholly groundless, fife or(raudulent.
SS), ( D RESS)
(SIGNA RE OF RELATIVE-ORL49AIL REP. AND ADDRESS)/
Adirondack Cii k
200 Smith OrWe
Corinth, W 12822
1518) 664-76W ' Fax (618) 654-7M