Webster, Warren Jr. 0.
TOWN OF QUEENSBURY
Pint Vieth Cemetery nod Crernnrnrtnrn
21 Qunker Rond. Queenshory, NY. 12804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: "K\
Name of Deceased: W g r" >�P +#r j r ,
Case Number: 3$
Date of Cremation:
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Time Cremation Started: 016 Ad.
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Time Cremation Complete
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
tol Rules and Regulations/to�cremate the remains of
(NAME 1 (SEX)
(STRE (CITY) (STATE) (ZIP CODE)
d of �`' P1�1 C� 20 p a
who died on day
P I
at
(PLACE) (ADDRESS)
7 an address of nearest riving relative or name of person authorizing cremation: I
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Relationship to deceased
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Name of Funeral Home ' t
IMPORTANT
I represent that to the best of my knowledge, the deceased ba
i or as o ' ker in his or her
body. (CIRCLE ONE)
a I have the full power and authorization to arrange for the cremation of the remains and
I certify that
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 any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed,whether
laims or demands are or are not wholly groundless,false or fraudulent.
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(WITNESS) (ADDRESS)
( NATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date:lar, a
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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 necessary. Prearrangements are
necessary for Saturday cremations.
2• A "Authodzatign for Cremation" signed by the nearest next of kin is necessary stating
that they do hate'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, whether
such claims are, or are not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate 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
Burial Transmit Permit and Authorization to Cremate Form. The cremated remains will
be mailed via Registered 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