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Bimonte, Salvatore TOWN OF Q UEENS B UR Y Pine View Cemetery and Crematorium 21 Quaker Road, Queensbury, NY. 12804-5902 (518) 745.4476 (518) 745.4477 http://w\vw.queensbury.net Funeral Director: -VI, 2 L � � Name of Deceased: 12� ✓l/6 ® j Case Number: Date of Cremation: 1 2 Retort: � L�-A (.�� �G l Z-- Time Cremation Started: Time Cremation Completed: - 1 14 Type of Container:Gib �� �`"T� �/G� y 7�r� Jr) L4J 1 'Al Remarks: " Home of NntitrnI Benuty ... A Good P I n c e to Live " i TOWN OF QUEENS6URY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745-4477(if no answer) Cemetery 745-44.76 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. [31- vn0-4I < yo — (NAME) (SEX) New (STREET) (CITY) (STATE) (ZIP CODE) who died on 14 t h day of J ca tl u a_ry 2086 Adrk Medical Ctr. , Saranac Lake, NY (PLACE) (ADDRESS) Name and address of nearest riving relative or name of person authorizing cremation: Matthew Bimonte 95 Balsam ,fit Bl a2 . T.akp- P1 ari d , NY Relationship to deceased Son Name of Funeral Home (Llud Jig 2310 Saranac Ave. Lake Placid, NY 12946 IMPORTANT I represent that to the best of my knowledge, the deceased has o(gawacemaker In his or her body. (CIRCLE ONE) I certify that I have the 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 C matorium from any and all claims and demands for loss or damages which may be made ;against them by reason of netted with the cremation of said remains as directed,whether such qr demands or a o hollr groundieis,false or fraud t. i ( TNESS) (AD RESS} '9-r B z tAti 's•% 134 a< 2 (SIGNATURE OF RELATIVE R LEGAL REP.AND ADDRESS) L D Signed on this date: � 3 DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mark.ttrk.Jnc. Mail to 2310 Saranac Ave. I.,R•IQ, PIP.c1d. VV Other arrangements - please specify: If pulverization of cremate remains is requested, check here ,- POLICIES, RULES p" REGULATIONS 1 . The crematorium will be open for cremations 5 days a week 7:Q0 A.M. - 3:30 P.M. Monday-Frida y.arrangements can be made for Saturday o Holidays n Sundays, telephone for acceptance of remains is necessary*arrangements by 2. Pine View Crematorium is located on the grounds of the View Cemetery, Quaker Road, Town of Queensbury. Pine 3. An authorization for cremation properly signed by the nearest next of kin or other authorized person 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 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 of damages which may be made against them by reason of or connected with the cremation of said remains and/or disposition of .remains as directed, whether such claims said demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular burial permit must accompany the remains. 4 . All remains must be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material. No Styrofoam or plastic containers will be accepted. 5. The question relative to cardiac acemers must be answered on the authorization to cremate form before the remains will be accepted. 6. Unless other arrangements are made the cremated remains will be mailed via Registered U. S. Mail within three days Of cremation to the funeral home handling the service. There will be a $25. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $300.00 Children (age 13 months to 12 years) $150. 0p Infants (stillborn to 12 months) $100. 00 * Additional $100. 00 charge for cremations done after 3:00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $100. 00 Any remains received after 3:30 P-M. Mon-Fri or Saturday will be charged an additional $100. 00.