Whitney, Joseph L O Y V N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director m /ZA��
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Name �') FPtf ( �' �� Case# t-1 I-1 11
Date Of Cremation 1 _ 2 CP L00 �J'
Time Cremation Started ) -I, y
Time Cremation Completed
Type of Container e, 2,
Remarks
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:
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( me) (Sex)
(Street) (City) (S e) (Zip Code)
who died on L day of t�G�f� - 20AJ--ZG //
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(Place ( ress)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased ✓�
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any operated +
device in his or her body. (Circle One) a•
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct wesition of the-
cremated remains,that any personal possessions have either been removed or may be destroyed,and ect,defend and
save harmless ' e View Crematorium from any and all claims and demands for loss or damages which. be made against them
by reason of nected with the cremation of said remains as directed,whether such claims or de le or are not wholly
groundless, seQr fraudu t. /
P� ,.
(W' (Address)
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(Signature and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to -
Other arrangements-Please specify: .
If pulverization of cremated remains is requested,check here
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
�e 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 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 rAmains must be in a casket or suitable alternate container. Caskets and containers
rrt of a combustible material. No styrofoam or plastic containers will be accepted.
4. C cemakers, defibrillators or other battery operated devices must be removed
befo remains will be accepted.
5. Crema i Will be completed within three working days(72 hours)of receipt of the
Burial'I� it Permit and Authorization to Cremate Form. The cremated remains will
be,mailed. Registered U. S. Mail within three days of cremation to the funeral home
handling rvice unless other arrangements are made. There will be a $25.00 charge
for this service.
a: 6. Cremation, Administration Costs and Recording Fees:
Aduk $300.00
Children (age 13 months to 12 years) $150.00
InfAts (stillborn to 12 months) $100.00
Overtime Cremations(Weekdays) $400.00
Saturday Cremations $400.00
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