Hunter, David Funeral Director: �� \
Name of Deceased: P, 14 E
Case Number: 2 1 CP
Date of Cremation: Z ''k — C9
Retort: e
Time Cremation Started: 14-1-1
Time Cremation Completed:
Type of Container: \"30 l3-)--
Remarks:
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
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Quaker Road, Queensbury, New York 12804 al
Phone (518) Crematorium 745-4477 (if no answer)
Cernetery 745-4476
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AUTHORIZATION TO CREMATE f
The undersigned requests and authorizes Pine View Crematorium, in accordance with apq subject
to its Rules and Regulations to cremate the remains of:
Q-A YJ U Ll Vhl � MALE- ;r
(NAME) (SEX)
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(STREET) (CITY) (STATE) (ZIP CODE) €l
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who died on Z ) day of i
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(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
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EL-12613my 1N HEAIrc/z -r - AVC/L/V/(-cE ZAVC LA cam I4A (1)- /Yy
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Relationship to deceased I/./
Name of Funeral Home
2310 Saranac Ave.
Lake Placid, NY 12946
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IMPORTANT ;
I represent that to the best of my knowledge, the deceased has has na acemaker imbis or her
body. (CIRCLE ONE) FI
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 e�iher been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Vi w,
Crematorium from any and all claims and demands for loss or damages which may be rrratle
against them by reason of or connected with the cremation of said remains as directed,W' iether
such claims or demand are or are not wholly groundless, false or fraudulent. i
(WITNESS) (ADDRESS) - '
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(SIGNATUR_ OF RELATIVE OR LEGAL REP, AND ADDRESS) OL ��� r�
Signed on this date:--r+` — 2J. 200,E
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DISPOSITION OF CREMATED REMAINS
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I hereby direct fine View Crematorium to dispose of the cremated remains as follows:
Mali to AN-16• aumt.30[.
Lake- Placid, NY 12946
other arrangements-please specify:�� -- —_-- -,.
if pulverization of cremated remains is requested, check here '"
POLICiES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M. TVriday
Friday, No Holidays or Sundays, arrangements can be made for Saturday, Prearr�I 96ments
by telephone for acceptance of remains is necessary.* r
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2. fine View Crernatorlum is located on the grounds of the Pine View Cemetery, Qua ,r�oad,
Town of Queensbury. `
3. An authorization for cremation properly signed by the nearest next of kin or other at th sized
person stating that they do have the power and authority to arrange for the cremafl bf the
remains and to direct the disposition of the cremated remains, that any personal p +swions
have either been removed or may be destroyed and agree to protect, defend and s v
harmless Pine View Crematorium from any and all claims and demands for loss or Pa gages
which may be made against there by reason of or connected with the cremation of t r d
remains and /or disposition of said remains as directed, whether such claims or de nds are,
or are not wholly groundless, false or fraudulent. This authorization in addition to aftevular
burial permit must accompany the remains. f :`
4. All remains must be encased in a casket or suitable alternate container, Caskets a5d,
containers n•iust be of combustible material. 1do Styrofoam or Mastic containers will bth-
accepted, 1
5, The question relative to cardiac pacemakers must be answered on the authorizati ` flo
cremate form before the rernains will be accepted. l
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6. Unless other arrangements are made the cremated remains will be mailed via Re, sti red
U.S, Mail within three days of cremation to the funeral home handling the service, a ljere will
he a $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$226,00 Children (age 13 6.onths to
12 years) $115.00 infants (stillborn to 12 months) $75.00 i
Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Frida .
Cremations dome on Saturdays will be charged the additional $60,00.
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