Jones, Donald S
TOWN OF Q UEENS B UR Y
Pine Vieth Cemetery and Crentntort ttnt
21 Qunker Rond, Qtteenshttry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp iiw\,nv queensbury net
Funeral Director: Y , Q Ch.14"�2-
Name of Deceased: bQ , C') Cj
Case Number: 3
Date of Cremation:
Retort: _1--CF
Time Cremation Started: �[� �✓�
Time Cremation Completed: --2) �-
Type of Container: CZ1,4-1Za nd- 4121 AAA. V ,
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Remarks:
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, QueensbUry, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745.-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with subje-cl,
to its Rules and Regulations to cremate the remains of: f!"
DONALD JONES MALE
(NAME) (SEX)
8 GRANDVIElq AVENUE LAKE PLACID NY 12946
(STREET) (ury) (STATE) (ZIP CODE)
who died on 28th day of —Seipf-prriher
at. _q n,R LAKE PALLID, NY 12946 siY �
(PLACE) (ADDRESS)
,.Name and address of nearest living relative or name of person authorizing 9 an:
r.
Georcfia Jones 8 GraDdview Ave. , Lak!kPlacid.
Relationship to deceased- IoVi f e fa
Name of Funeral Dame M B Clark, Inc. 2310 Saranac Avknpe
Lake P1 ld, NY 12946
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 13p.'pacdimaker in io or her
body, (CIRUE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the ftpositlon of the cremated remains, that any Dersonal possessions have e.fih r been
removed or may be destroyed, and agree to protect, def and save harmless Pine VAA
Crematorium from any and all clairns; and demands for to or damages which may be �iade
against them by reason of or connected with the cremation&aid,remains as dirAted,' 6ether
such Clair 11 or dernands are of,are not wholly groundless,fffe or fraudulent-
_
2310 Saranac..'Ay_���. Lake Placid, NY,Y%`
(W (ADDRESS) 12946
8 andview Ave. , LaXe. PiaciO, NY 2946
(SIQ;tT1JRE )F REL.ATIVE L.EGAL OR REP AND ADDRESS) It
Signed on this date: tpt. 28, 2005
A
DISPOSITION OF CREMA"f eD REMAINS
�f
I hereby direct tine View Crematorium to dispose of the cremated remains as follows: } l
Mail to 0I.g.(filarlk.
Lake Placid, NY 12946
Other arrangements-please specify-
if pulverization of cremated remains is requesLed, check here l�
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POL.ICWS, RULES AND REGULATIONS
1. The crernatorium will be open for cremations 6 days a week 7.00 A.M. - 3:30 P,M, Mprictay-
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearraitgementr
by felephone for acceptance, of rernains is necessary,* p
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2, fine View Crematorium is located on the grounds of the Pier, View Cemetery, Quake r-V gad,
Town of Queensiariry. {#
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3. An authorization for cremation properly signed by the nearest next of kin or other m.4-horizod
Person stating that they do have the power and authority to arrange for the crerriaticttr bf thfz
remains and to direct the disposition of the cremated remains, that any personal pc���ssiernr5
have either been removed or may be destroyed and agree to pratect, defend and E'nages
harmless fine View Crematorium frr,,i„ any and ail claims and demands for loss or
whiQh may be made against them by roason of or connected with the cremation ofP)d
remains and for disposition of said rent ains as directed, whether such claims or deg!hdrids are,
or are not wholly groundless, false or frr ud«lent, This authodzation in addition to
.bi,rfi l nPrmit must accompany the remai�is.
A. All remains mu t be encased in a casket c,f suitat')le alternate container. Caskets a-frd
rontahierrs n•ius of combustible maleria{ No Styrofoarn or plastic contallle✓rs will;b6
accepted. :I
6,, The question relrative to cardiac )acernakers -nust be answered on the authorizafl i to
t ;.rbiOrnate form before the rernaira will be acc:e,4ed. r
�* 6, t.iniess other arT ngernerits r,e rnada the crema -id remains wilt be mailed via RegIN- red
l.J.y• Maii within three days r f cremation to the fur oral harm handling the service✓, gi,ore will
be a 00.60 charge for t aervice. ; i
Cre atibn, Adrrildisb,ation C*s and Recording Fee, Adult$225,00 Children (age 13�h�7r,nt:t7
12 yf' rj) $115,00 infan*411born to 12 months) $75,00
Additional $50- change for cre-oration, done after 3.of) P.M. 0)1.0ay through Friday,
C;rematians done on Satutdays will be charged the additional $6().f.0,
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