Sheridan, Norma TOWN OF Q UEENS B UR Y
Pine View Ceutetery mid Crematorium
27 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http//w\v\v queensbury net
Funeral Director: -
Name of Deceased:
Case Number: �--
Date of Cremation: 1 le ' 200
Retort: �/�� `liU �C� `j
Time Cremation Started: �� -Time Cremation Completed:
Type of Container: \Z- Lot)0 C yorKC,�V � ►a � t� � � �� ��'`
Remarks:
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" Home o/ Nnturol Benuty ... A Good Plnie to Live "
Policies, Rules and Regulations
1. Pee 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 necessary.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,whetter
such claims are, or are not wholly groundless,false or fraudulent. This audxmization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable awe 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 days(72 hours)of receipt of the
134rial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Reed U. S. Mail 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
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of..
NORMA P. SHERIDAN FEMALE
(Name) (Sex)
37 GEORGE ST . , FORT ANN , NEW YORK 12827
(Street) (City) (State) (Zip Code)
who died on 2 N D d,,y nt A P R I L 200 5
at BERKSHIRE MEDICAL CTR . , PITTSFIELD , MA
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
VICTORIA B . HOLLEY , 949 MEADOW LANE , NISKAYUNA , NY. 12309
(Name) (Address)
Relationship to the deceased DAUGHTER
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,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 have 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 wilier 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 maybe nrede against them
by reason of or connected with the cremation of said remains as directed,whettier such claims or demands are or are not wholly
groundless,false or fraudulent.
, NY, 12827
(witness) (Address)
(Signahue of Relative Ot Legal Representative)
Signed on this date: X� 3i - Go '5
Disposition of Cremated Remains
I hereby direct Pine View C emala ium to dispose of the cremated remains as*Rows:
Mal to
Other arrangements-Please specify:
If puivenzation of cremated remains is requested,check here
Revision:July 7,2004
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