Porter, Gary TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, NY. 12804-5902
(518) 745-4476 (518) 74 5.447 7
htcp//w,,v%v.queensbury.net
Funeral Director: C 1`4 lZ b
Name of Deceased:
Case Number:
Date of Cremation:
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Time Cremation Started:
Time Cremation Completed:
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Remarks:
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" Noma of NnturnI Benitty ... A Good Plnce to Ltue "
TOWN OF QUEENSBURY
AU PINE VIEW CEMETERY
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CREMATORIUM
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Quaker Road, Queensbury, New York 12804
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Phone (518) Crematorium 745-4477 (if no answer)
Cernetery 745.4476
AUTHORIZATION TO CREMATE �I I
Tile undersigned requests and authorizes Dine View Crematorium, in accordance with aW'subject:
to its Rules and Regulations to cremate the remains of:
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(NAME) (SEX) i
(STREET) T ((77 (STATE) (ZIP CODE) , � �
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who died on 7-6 day of _ J U Al
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at Ul 11,_ LLL�L`� mac/ CCiSl TtIL _.�. �4/c /�I-A C ,0 /v
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation: j
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Relationship to deceased DPI v CH
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M.N. (Mark,31ac. <. i
Name of Funeral I come _ 233 019asa-an 1Ave.—
Lake Placid, NY 12946 I
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IMPORTANT !
I represent that to the best of my knowledge, the deceased has has no pacemaker inah(b or her
body. (CIRCLE ONE)
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I certify that I have the full power and authorization to arrange for the cremation of the rN�m-ains and
to direct the disposition of the cremated remains, that any personal possessions have ei:her been
removed or may be destroyed, and agree to protect, defend and save harmless Pine VI«v
Crematorium from any and all claims and demands for loss or damages which may be rbabe
against them by reason of or connected with the cremation of said remains as directed,iw(lether
such claims or dernands are or are not wholly groundless, false or fraudulent. i
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(WITNESS ) (ADDRESS) '
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(SfGNATUR._ OF RELATIVE OR LEGAL REP. AND ADDRES '`
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Signed on this date:--W
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DISPOSiTION OF CREMATED REMAINS
I hereby direct fine View Crematorium to dispose of the cremated remains as follows;
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Mail to •'� 3ttr.__
� idi51 anac Ave.
Lake Placid. Ny 1254
Other arrangements-please specify.---
If
if pulverization of cremated remains is requested, check here )e
POLICiES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 RM. d1 llj 'day•-
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrahgbments
by telephone for acceptance of remains is necessary.*
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2. fine View Crematorium is located on the grounds of the Pine View Cemetery, (qua �r 0oad,
Town of Queensbury.
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3. An authorization for cremation properly signed by the nearest next of kin or other aL thorized
person stating that they do have the power and authority to arrange for the cremati. of the
remains and to direct the disposition of the cremated remains, that any personal p ° 4�ssions
have either been removed or may be destroyed and agree to protect, defend and s. v6
harmless Pine View Crematorium from any and all claims and demands for loss or ' riages
which may be made against them by reason of or connected with the cremation of a d
remains and for 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 Aei ular
burial permit must accompany the remains.
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4. All remains must be encased in a casket or suitable alternate container, Caskets a rrcEr
containers rriust be of combustible material. No Styrofoarn or plastic containers will b,
accepted. tl
5. The question relative to cardiac pacemakers must be answered on the authorizatif to
cremate form before the remains will be accepted. C
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6. Unless other arrangements are made the cremated remains will be mailed via Re st.hred
US, Mail within three days of cremation to the funeral home handling the service, r Ylere will
he a $20.00 charge for this service. rl i
Cremation. Administration Costs and Recording Fee: Adult$226,00 Children (age lAnonths to
12 years) $115,00 Infants (stillborn to 12 months) $75.00
* Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $60,00.
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