Hathaway, Elaine 70 q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1413 cl"rk
:Name 'Iuine yw q Case# yU b
Date Of Cremation I /s o
Time Cremation Started 5115 A4 H .
Time Cremation Completed(( (i UU A , I
Type of Container C6r4.ihact�rci �St CSS� L, 1E
Remarks
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TOWN OF QUEENSBURY
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PINE VIEW CEMETERY
CREMATORIUM I
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Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer) ;f
Cemetery 745.-4476
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AUTHORIZATION TO CREMATE
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The undersigned requests and authorizes Pine View Crematorium, in accordance with at subject
to its Rules and Regulations to cremate the remains of,
ELAINE E. HATHAIJAX
(NAME) (SEX)
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(STREET) (CITY) (STATE) (ZIP CODE)
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who died on 2nd day of October 1109
at AMC at Saranac Lake ,
(PLACE:) (ADD ES ) Dr'-' Sar-ana
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Name and address of nearest living relative or name of person*authorizing cremation:
William D Hathaway P 0 Box 1 , Jy, NY 12243&_
Relationship to deceased Husband
Name of Funeral Horne v.
2310 Saranac Ave.
Lake Placid, NY 12948
IMPORTANT r
I represent that to the best of my knowledge, the deceased has or' cq pacema0r inahip or her
body. (CIRCLE ONE) «
I certify that I have the full power and authorization to arrange fo rs th " i and
to direct the disposition of the cremated remains, that any perso n
removed or may be destroyed, and agree to protect, defend and r 'P,irld
Crematorium from any and all claims and demands for loss or d h may be'
against them by reason of or connected with the cremation of sat` eml asi ire cted, her.
such claims or demands are or are not wholly groundless, false`or frauttt "� �.
2310 Saranac Ave. , . a ` ' � �
ww.r.wn..r.
(WETADDRESS) '
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(SIGNATURE_ OF ELATIV OR LEGAL. REP. AND )
Signed on this date: Oc 2 , 2005
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DISPOSITiON OF CREMATED REMAINS
I hereby direct fine View Crematorium to dispose of the cremated remains as follows, °► i
Mali to 0A.S.
,-� Smamw
Lake Placid, ITY 12946 '
Other arrangements-please specify.-
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if pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
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1. The crematorium will be open for cremations 5 days a week TOO A.M. - 3:30 P.M. ��()riday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearral�ybments
by telephone for acceptance of remains is necessary.`
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quak road,
wn of Queensbury. j '
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3, An authorization for cremation properly signed by the nearest next of kin or other aL.thcarized
person stating that they do have the power and authority to arrange for the cremation bf the
remains and to direct the disposition of the cremated remains, that any personal p ' sessions
havg either been removed or may be destroyed and agree to protect, defend and s< via
harmless Pine View Crematorium from any and all claims and demands for loss or .a�nages
which i*y be made against them by reason of or connected with the cremation of paid
remain id /or disposition of said reains as directed, whether such claims or de,iMinds are,
or are OR m
wholly groundless, false or fraudulent, This authorization in addition to a,reqular
burial permit must accompany the remains.
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4. All remains must be encased in a casket or suitable alternate container, Caskets arrci
containers rriust be of combustible material. No Styrofoam or plastic containers wil j bn
accepted.
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5. The question relative to cardiac pacemakers must be answered on the authorizati ` to
to form before the rernains will be accepted.
B. .0 o her arr ngements are made the cremated remains will be mailed via Reg stored
�+► ( Rhin r4ree days of cremation to the funeral home handling the service, �P ere will
be. bharge for this service. .j
CPEmatton, inl ration Costs and Recording Fee; Adult$225,00 Children (age 13'ponths to
:of jeaiA) .00 intents (stillborn to 12 months) $75.00 R,
` l'.Id tors 450.00 charge for cremations clone after 3:00 P.M. Monday through Frida��.
t 7 done on Saturdays will be charged the additional $50,00.
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