Locke, Amaryllis Funeral Director: /►I °-) n
Name of Deceased: �►/y1IzIrz, !:I ( `�
Case Number: e) ~� oj
Date of Cremation: C.e.� t ''�� 2c'r0
Retort: (::?,�z P,uJi:5-(j kZJ
Time Cremation Started:
Time Cremation Completed: 'l —./ d P 'mil I
Type of Container: G Ax&D f3 a A �L PJ 6
Remarks:
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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.
AMARYLLIS R . LOCKE FFMAIF
(Name) (Sex)
1672 STATE RTE . 9, So . GLENS FALLS , NY. 12803
-- 1 � (City) (State) (Zip Code)
who died on 10 T H day of U N E 2005 - --- -- --- _.
at GLENS FALLS HOSPITAL , 100 PARK ST . , GLENS FALLS , NY. 12801
(Place) (Address) I
Name and address of nearest living relative or name of person authorizing cremation:
SUSAN M. PETERS , SAME AS ABOVE
(Name) (Address)Relationship to the deceased D A U G H T E R
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I 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 either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from arty and all claims and demands for bee or damages which maybe nrede agai I them
by reason of or connected with the cremation of said remains as directed,whether such ciah, or demands are or are not whoilly
groundless,false or fraudulent. `I
( )
SAME AS ABOVE
(Sigiiahrre and Address of Relative or legal Representative)
Signed on this date: .JL'A� /d
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
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Other arrangements-Please specify:
If pukwurtion of cremated remains is requested,check here
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Revision:July 7,2004
Policies, Rules and Regulations
1. Pine View Crematorium is boated 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 ofsaid remains as directed,wtxMh>er
such claims are, or are not wholly groundless,Use or fraudulent.This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or sortable alternate container.Caskets and containers
must be of a combustible material. No styrolloam or plastic containers vAH 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 whhin three working days(72 hours)of receipt of the
154rial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U. S. Mad w0dri 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