Lobo, Veronica TOWN OF QUEENSBURY
Purr Vireo Cemetery nnrl Crrmn tort um
21 Qunker Ronr1, Queensbury, NY. 12804-5902
(518) 745-4476 (518) 745.4477
harp iiw\v%v queensbury.net
Funeral Director: A4 S ® 1\l
Name of Deceased: t/-Q
Case Number:
Date of Cremation: T7
Retort: !.{] rG
Time Cremation Started: ' �l
Time Cremation Completed: .��J
Type of Container: �l ,/J� -� ►1/)
Remarks:
" Honer of NnfurnI 8enufy ... A Goo l PInir io L c
3�D
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 aul ortzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
VERONICA J . LOBO FEMALE
(Name) (sex)
11568 STATE RTE .22, COM10—CK , NEW YORK 12821
(Street) (City) (State) (Zip Cam)
who died on 15TH dayof .JULY 2o05
atINDIAN RIVER REHAB . & HEALTHCARE CTR . , GRANVILLE , NY.
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
DEBRA LOBO , 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.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)orqEFRj pacemaker,defiWiiator or arty other battery operated
device in his or her body. (Circle One) Hry.
I certify that I have fur power and aulhorbatim 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 pnd
save harmless Pine View Crematorium from any and all dam and demands for loss or dmoges which may be am*apainst,tlre n
by reason of or connected with the cremation of said remains as directed,whether such chins or demands are or are not whory
less,false or fraudu
. Box 277 , FORT ANN , NY. 12827
ia,ess> O
SAME AS ABOVE .
Signature and Address Relative or Legal Representative)
Signed on this date: .J U L Y 16 , 2 0 0 5
,
Disposition of Cremated Remains
I hereby direct Pine View Crerr atmm to dispose of the cremated ream* as forows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,deck here 12
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 nay.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 diispositiorn 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 remalos as directed,whether
such claims are, or are not wholly groundless,false or fraut.This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate corgi.Caskets and corers
must be of a combustible material. No styrofoam or plastic containers vAll 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
B4rial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Regis red 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