Bontecou, Dorothy TOWN OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �& J�
Name ` G' d ��'fil��J�� Case#
Date Of Cremation 7�- Z G ✓
Time Cremation Started
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Time Cremation Completed
Type of Container -lf ( J(p;` �i i% G lJ/�' `� ;�✓� �, t�� C� 1�✓Jn
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pkkv-Vow Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Dorothy E. Bontecoit Fem le
(Name) (sex)
74 Oneida AvP,nue, Lake Pl,ar-id, NY 12946
(Street) (City) (State) (Zip Code)
who died on _._ 7 t h day of Ap r i j 20 0 6
at Adrk Medical Center, Saranac lake, NY
(per) (Awres's)
Name and address of nearest living relative or name of person a dwizing cremation:
Dorothy E. Bontecotz 74 Oneida Ave. , Lake Placid, NY 12946
(Name) (Address)
Relationship to tho deceased Self
Name of Funeral Home M B C1arkL Inc. , 2310 Saranac Ave., Lake Placid, NY
IMPORTANT: tpr or any other battery operated
I represent that to the hest of my knowledge,the deceased(has)or� m pacemaker,
device in his or her body. (Circle One)
I certify that I have.fup power and authorization to arrange for the cremation of the remains and to direct the td proHof the nd and
cremated remains,that any personal possessions;have either been removed or may be destroyed, made against them
save harmless pine Vie Crematorium iroin any and all daims and demands for loss or damages which may
be by reason of'or connected with the cremation of said remains as dated,whether much claims or demands are or are not wholly
groundless,false or fraudulent.
�CQ � 2310 Sa an a cAve , Lake Placid, NY 12946
(Address)
(witness)
: 74 Oneida Ave. , Lake Placid, NY 12946
(Sig ature and Address of Relative or Legal Representative)
Signed on this date:4L _ F e b 2 8 . 2 0 0 6 _
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows.
Mail to _- --- - —
Other arrangements-Please specify: "-
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:00am 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 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 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.
a. Cardiac pacemakers, defibrillators 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
Burial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handiing'the service unless other arrangements are made.There will be a $30.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00