Lutz, James 70%N OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ M 13 Ok9- I� `
Name TAA c/e7 Case# LO
Date Of Cremation 05,
Time Cremation Started
Time Cremation Completed l q4— PA,3
Type of Container (/lf�•��- j 022- --
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY s I
&
CREMATORIUM
;quaker Road, Queensbury, New York 12804 FI
t, Ph6ne (516) Crematorium 745-4477 (if no answer) ;
* Cemetery 745-A476 1
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AUTHORIZATION TO CREMATE `I
Tii@ undersigned reque 'nd authorizes Pine View Crematorium, in accordance with a( G subject
to.its Mules and Regulatio to cremate the remains of:
• James kicl ae-1 Lutz Male
(NAME) (SEX) »..._
t
}8 5 01 d .M i 1"i'
•' 3Yr..Rd. . Lr�a P. .c. 12946
($T E T1 #• , (CITY) (STATE) (ZIP CODE)
who died on 2 fi
day of November ?I 005
4AAALIMM,111 :.
d-A edical Center, Saranac Lake, NY '
(ADDRESS)
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ress of nearest living relative or name of person authorizing cremation: `
tiety 2393 Pzztman Road, Ontario, NY 14519 :I
Rel nship to deceased Sister
e Name df Funeral Home M B Clark, Inc. , 2310 Saranac Ave. , La le Placid,NY
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker inahio or her
body. (CIRCLE ONE) �I
I certify that I have the full power and authorization to arrange for the cremation of the rdrnains and
to direct the disposition of the cremated remains, that any personal possessions have a her been
removed or may be destroyed, and agree to protect, defend and save harmless line Vipbvv
Crematorium from any and all claims and demands for loss or damages which may be rpa'de
against them by reason of or connected with the cremation of said remains as directed,IM,ether
such clgims or demands are or are not wholly groundless, false or fraudulent. i
I
2310 Saranac Ave. , Lake Placid, N1'
(WITNESS) (ADDRESS)
�AlhR2393 Putnam Road, Ontarion, NY 1,4$19
(SIG NPUR ZU REL IVE OR LEGAL REP, AND ADDRESS)
Signed on this date:Nov. 3 , 2.005
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DISPOSiTION OF CREMATED REMAINS
I hereby direct Fine View Crematorium to dispose of the cremated remains ds foli4c.": I
Mail to
Other arrangements-please specify:— --
if pulverization of cremated remains is requested, check here `{'' •
POLICIES, RULES AND REGU-�it7N,�
1. The crematorium will be open for cremations 5 days a we :0�X. -"3:30 RM. IViI d ay-
Friday. No Holidays or Sundays, arrangements can be 1718 for Saturday.. Pre'arra igpments
by telephone for acceptance, of remains is necessary."
2. Fine View Cretnatorlum is located on the grounds"of the P'" 0ed,
Town of Queensbury.
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3. An authorization for cremation properly signed by the nearest next of.kin. other d h�rized
person stating that they do have the power and authority to arrange; f the
remains and to direct the disposition of the cremated remains, t0kat:3 1 p sons
have either been removed or may be destroyed and agree to protect.
harmless Pine View Crematorium from any and all claims and demand ss or a ages
which may be made against them by reason of or connected with the cremation of c,'
remains and /or disposition of said remains as directed, whether such claims or de' .nds are,
or are not wholly groundless, false or fraudulent. This authorization in&,ddi. a eoular
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets a d
e of combustible material. No Styrofoam or plastic containers wh
containers must b il b� .
accepted. '
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5, The question relative to cardiac pacemakers must be answered on the authorizati '1 {o
cremate form before the rernains will be accepted. ;
B. t.lniess other arrangements are made they cremated remains will be mailed via Re, shred
1).S. Mail within three days of cremation to the funeral home handling the service. ,, f ere will
be a $20.00 charge for this service.
t
Cremation, Administration Costs and Recording Fee: Adult$226,00 Children (age 13 ninth. to
12.years) $115.00 Infants (stillborn to 12 months) $75.00
* Additional $50.00 charge for cremations done after 3.00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.
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