D'Andrade, Eda i
T07+N of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director L 1-k
Name ��� � N���� Case# �p
Date Of Cremation JI 2 Zl�G
Time Cremation Started p/V�
Time Cremation Completed
Type of Container H i4
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Ftaker 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:
(Name) (Sex)
A N e her row.)
(fit) it* (State) (Zip Code)
who died on I It e. 02 Q 1�t day of NO d em be 20
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at
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(piece) >
Name and address of nAarest living relative or name of person authorizing cremation:
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_ 'Fe�- .j`* •Q A w J r A d.e— 'I Jt f S i�j",, R r � �,�os r�—�O��✓ N '. /7
(Vme) (Address)
Relationship to the domed d// A u q 7 it—
Name of.Funeral Florthe 4,4 cd rA h rl L /64/✓ r ,V t r A
IMPORTAN
I represent my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in hls: Circle One)
I certify that 1 and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated rema 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,whetter such claims or demands are or are not wholly
groundless,false or fraudulent. n I /
1 A4cnr /Z Po e-rv� c A y • /.Z� o
( ) (Address)
� 7 � ► 9 C1-.eS�e�•�cw .J �u • ��
ignature and Address of Relative or Legal Representative)
Signed oh this d#— &0Il e*n 6 t•— ;k I Z U QS
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdkhws:
Mail to_ W i l pi`c JC y.
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
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 Iny 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 pnd all claims and demands
for loss of damages which may be made against them*.16son 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 rr1 removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 hours)of the
Burial Transmit Permit and Authorization to Cremate Form.The cremat ains 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