Midlam, Catherine 7074N OF QUEEVBUP,
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Fune�,/
l DirectorName �/�� V 4-41 Case#
Date Of Cremation ( - -z- - 2---00
Time Cremation Started ( ® 0 "1-
Time Cremation Completed
Type of Container C/ik-,2-!J d(-t12- �_
Remarks
2. a2
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 7454476
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AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with a(ho subject
to its Rules and Regulations to cremate the remains of:
-} LnJ /VL' V I—A 22 Female F
(NAME) (SEX)
420 Old Military Road, Lake Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE}
YI
who died on 29th day of on-pber
at [Jihlein Mercv Center, 420 01 1
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:`
1.
M 21, r. I
Relationship to deceased Grandson
A.M. (11arlk.jut. *.
Name of Funeral Home
Lake Placid, NY 12946 ,
IMPORTANT •�`'�
I represent that to the best of my knowledge, the deceased has o as pece jj aker to Nbkher
body. (CIRCLE ONE) •` �'
i certify that 1 have the full power and authorization to arras or the cr e r M ins and
to direct the disposition of the cremated remains, that any pe a!posy "ti� h r been
removed or may be destroyed, and agree to protect, defend and ri0ve-harmless,&�irre�t�.
Crematorium from any and all claims and demands for loss Ci damages which mart Irade
against them by reason of or connected with the cremation of mid remains as directAd,* m6l ether
such claims or demands are or are not wholly groundless,-Jqbe or fraudulent.
r 2510 Saranac i
(WITNESS) 3 (ADDRESS)
x 78 Haselton Rd.
(SIGNATURE OF RELATIV R LEGAL REP, AND ADDRESS)
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Signed on this date: Q G% ' . • ,
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DISPOSITION OF CREMATED REMAINS
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I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to i
2310 Saranac Ave. r ,
Take
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Other arrangements-please specify: a
If pulverization of cremated remains is requested, check here_
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POLICIES, RULES AND REGULATIONS
- is
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. �f rjday_
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrat7q meats
Y by telephone for acceptance of remains is necessary.`
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quak r';Road,
Town of Queensbury. I
3. An authorization for cremation properly signed by the nearest next of kin or other aL thprized
person stating that they do have the power and authority to arrange for the cremati f the
remains and to direct the disposition of the cremated remains, that any personal p s ssions
have either been removed or may be destroyed and agree to protect, defend and sf.via
harmless Pine View Crematorium from any and all claims and demands for loss or latnages
*j hich may be made against them by reason of or connected with the cremation of a d
refrains and /or disposition of said remains as directed, whether such claims or de aI.nds are,
of'bre not wholly groundless, false or fraudulent. This authorization in addition to a eoular
• =burial permit must accompany the remains.
• • AH retrains must be encased in a casket or suitable alternate container. Caskets aid:
•''' + contain must be of combustible material. No Styrofoam or plastic containers wit be
.�
' accepted.
5 • The qu% ion relative to cardiac pacemakers must be answered on the authorizati o
•+� ,' I. .cr�i�at�fp�m before the remains will be accepted. f l
h [angements are made the cremated remains will be mailed via Re stored
•• ,ram�•� FJ, aitwlthin three days of cremation to the funeral home handling the service, mere will
..• "be a $20.00 charge for this service.
CremaLtion, Administration Costs and Recording Fee: Adult$226,00 Children (age 13 onths to
12 years) $115.00 lnfa�ft(stillborn to 12 months) $75,00
* Additional $50,00 charge for cremations done after 3.00 P.M. Monday through Frida?.
Cremations done on Saturdays will be charged the additional $60.00.
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