West, Ronald TOWN OF QUEENSBURY
Piste View Cemetery and Crematorium
21 Quaker Road, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http.//wNv\v queensbury net
Funeral Director: AA l 5 ® ��
Name of Deceased: tG
Case Number: > 3
Date of Cremation:
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Time Cremation Started: r)
Time Cremation Completed: q � �c .
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Type of Container:
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" Home o/ Natural Ben it y ... A Good Place to Live "
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: 518-745-4476,Crematorium: 518-745-4477
Authorization to Cremate
The undersigned requests and author¢es Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of,
RONALD LEE WEST MALE
(Name) (sex)
44 CiAY HILL RD., FORT ANN , NEW YORK 12827
(Street) (City) (fie) (Zip Cam)
who died on 2 8 T H day of MARCH 20 0 5
at GLENS FALLS HOSPITAL , 100 PARK ST . , GLENS FALLS , NY. 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorblrig cremation:
JULIA WEST , SAME AS ABOVE
(Name) (Address)
Relationship to the deceased WIFE
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no aker,detbrillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 have full power and authorbadon to arrange for the cremadon of the remains and to direct the disposition of the
wed rernains,that any personal possessions have e0w been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and al claims and demands for loss or damages which may be nude against them
by reason of or connected with the cremation of said remains as directed,whether such catrrhs or demands are or are not wholly
roundless,false or fraudulent.
//..�� .�i�n�n�,�.P.O . Box 277 , FORT ANN , NY. 12827
(witness) ( )
SAME AS ABOVE
r (Signature and Address of R Legal Representative)
Signed on this date: M A_R r H 7 A , 7 0 0 5
Disposition of Cremated Remains
I hereby direct Pine View Cremaiortum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
K pulvervotion of crenated remains is requested,check here
Revision:July 7,2004
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are neon.Prearrangements are
necessary for Saturday cremations.
2. A 'Authorization for Cremation'signed by the nearest next of kin is necessary 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 Cemetery and 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 are, or are not wholly groundless,false or fraudulent.This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable akernate container.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted
4. Cardiac pacemakers,defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working clays(72 horns)of receipt of the
44rial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U. S. Mad within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a $25.00 charge
`for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $300.00
Children (age 13 months to 12 years) $150.00
Infants (stillborn to 12 months) $100.00
Overtime Cremations(Weekdays) $400.00
Saturday Cremations $400.00