Clark, Alice 70 WN OF QUEEN5BU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ice--` 1z 1 ' Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container #&jZJyePd "e,
Remarks
i
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, QueensbUry, New York 12804
Phone (518) Crematorium 746-4477 (if no answer)
Ce
metery.tery 7�54476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with
d subject
to its Rules and Regulations to cremate the remains of
Alice D. Clark Female
(NAME) (SEX)
275 Alstead Hill Road, Keene, NY 12942
(STREET) r,
(CI-Ty) (STATE) (ZIP CODE)
who died on 16th day of Oct abpr
L
at 275 Alstead Hill Road, Keene,i NY 12942
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing crerTr&on:
Mrs Pamela Bickle 199 1fic[more
n TAI
r.a a V
Relationship to deceased Daughter
Name of Funeral Horne M B Clark, Inc. T.A
Pff,&id, N�
IMPORTANT
I represent that to the best of my knowledge, the deceased has o pacemaker fin hi�lor he'
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange fo)e cremation of the'r Pns and
Ir �
to direct the disposition of the cremated remains, that any perso I p ssessions have h�6r been
ga o Iii
removed or may be destroyed, and agree to protect, defend ant-save harmless Pine
Crematorium from any and all claims and demands for loss or ages which may be dde
against them by reason of or connected with the cremation of sa Gins as directed,IIW61 ether
such claims ernands are or are not wholly groundless, false or fraudulent.
t A 2-310 Saranac-Ave*. ,Make Placid ,
DRESS)
'W
lVgmore tane, Saranac NY
99 i
Lace,
(AGNATURE OF P I ATIVE OR LEGAL REP. AND�?OESS)
Signed on this date: Oct. 18 , 2005
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DISPOSiTION OF CREMATED REMAINS
I hereby direct fine View Crematorium to dispose of the cremated remains as follows;
Mail to
Funeral Director will ick tz
Other arrangements-please specify: � P cr�main.�
on Friday, Oct. 21 , 2005 E �
if pulverization of cremated remains is requested, check here xx
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. -3:30 P.M. i Lrjday,-
Friday. No Holtdays or Sundays, arrangements can be made for Saturday. Prearr ll�gpments
by telephone for acceptance of remains is necessary.` r
1l
• 2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Qua�ar Road,
Town of Queensbury. !;
3. An authorization for cremation properly signed by the nearest next of kin or other a th% rized
pers-on stating that they do have the power and authority to arrange for the crematrrin bf the
ren s and to direct the disposition of the cremated remains, that any personal p ' gpssions
ha ither been removed or may be destroyed and agree to protect. defend and s vt
h Pine View Crematorium from any and all claims and demands for loss or 1ainages
' rh _ y be made against therm by reason of or connected with the cremation ofad
lid /or disposition of said remains as directed, whether such claims or der„ �nds are,
wholly groundless, false or fraudulent. This authorization in addition to afreouiar
} i permitpust accompany the remains.
i�
{; 4
4. All reftJns must be encased in a casket or suitable alternate container. Caskets 4d
contalp r>�`ust be of combustible ►naterial. No Styrofoam or plastic containers wil,'bc-
3. ;j
accep
+ ,6 The,gp ative to cardiac pacemakers must be answered on the authorizati ` to
cremate= fore the remains will be accepted.
B. Unless other ngements are made the cremated remains will be mailed via Re, sti?redU3, MailwithIna
ree days of cremation to the funeral home handlin the servicx. ,Here will
Y 9
f
be a $20.00 cha for this service. i
f�
Cremation, Admiri! ion Costs and Recording Fee: Adult$226.00 Children (age 13.�mt�nthsc to
12 years) $115.00 n nts (stillborn to 12 months) $75,00 i
Itf
* Addltlonal $50.0 l arrge for cremations done after 3.00 P.M. Monday through Friday.
Cre tbns done turdays will be charged the additional $r0,00.
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