Moore, Cameron C
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker 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:
CAMERON B . MOORE MALE
(Name) (Sex)
29 EAST BEACON ST . , GLENS FALLS , NY. 12801
(Street) (City) (fie) (Zip Cam)
who died on 8 T H day of Noy. 20 05
at RESIDENCE
(place) (Address)
Name and address of nearest living relative or name of person authorizing crenwtiori:
Cnii FN GOODMAN 530 WFST FARM WOODS LANE , FORT ANN , NY. 12$27
(Name) (Address)
Relationship to the deceased D A U G H T E R
Name of Funeral Home MASON FUNERAL HOME , FORT ANN , NY. 12827
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has rro maker,defibrillator or any Wier battery operated
device in his or her body. (Circle One)
I certify tug I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that 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 demapes which may be made agetnst them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands ds are or not wtv*
false or fraudulent.
, P .O . Box 277 , FORT ANN , NY.%12827
( )
��(SV�mtweand Address�ofelatW or Legal Representative)
Sign,on this dace: Nov. 13 , 2005
Disposition of Cremated Remains
I hereby direct Pine View Crematorium m dispose d the mmaNd remains as follows:
Mail to
Other arrangements-Please spec fy:
if puh erization of cremated remains is requeste0l W e&here X X
Revision:July 7,2004
TOWN OF QUEENSBURY
Pine View Cemetery and Crenintorium
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http://w\v\v,queensbury.net
Funeral Director: JII Ptj 0
Name of Deceased: C-P/Y L 0 0 V
Case Number:
Date of Cremation: A
Retort &R A-to C%oR- U
Time Cremation Started: y �`
Time Cremation Completed: / 0 �'
Type of Container:
Remarks:
c�tG 4-41
Policies, Rules and Regulations
1. tie View Crematorium is located on the grounds of Pine View Cemetery.The
c ernatonum operates IN19nday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acoeptance of rernains are necessary.Prearrangements are
necessary for Saturday cremations.
2. A `Authorization for Crernation'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 remak-, ,that any 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 and all claims and demands
for loss of damages which may be made against them by reason of or connected with
the cremation of said remains and/or disposition of said rernalos as dmeckxk whether
,spch claims are, or are not wholly groundless,false or fraut.This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or sable akternate contairger.Caskets and contamers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers,defibriilators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
134MI.Transmit Permit and Authorization to Cremate Form. The cremated remains will
be hied via Registered U. S.Mai within three days of cremation to the funeral home
handing the service unless other arrangements are made.There will be a$25.00 charge
`for tVis 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
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