Warren, Nancy r'oQUEEVBUP.� � o�
,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Al VA, ^C&
Name Na Wc.rryh Case#
Date Of Cremation 6�
Time Cremation Started Ip ; 0
Time Cremation Completed
Type of Container
Remarks
3 }�
11 '40
I
13
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:
_ A1.4 C,(/ A, %�flil�0l'�/- Female
me) (Sex)
992 Olmstedville Rd. , North Creek, NY
(Street) (City) (State) (Zip Code)
who died on 2 7 t h clay Of April 20 06
at Adk Tri-Co . Health and Rehab Center , N. Creek
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Lorene Kelly, 4043 Star Trek Ln. , Garland Tx
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander Funeral Home, Inc .
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
i certify that 1 have full power and audxxt etion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that arry personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless fffwitr.�",
It=Ir m any and aN cairns and demands for loss or damages which may be made against them
by reason ofcremation of said rernrains as directed,whether such calms or demands are or are not wholly
ground I (Address)
-� Garland, TX
% (Signature and Address of five or Legal Representative)
Signed on this date: 0 4/2 8/2 0 0 6
Disposition of Cremated Remains
I hereby direct Mine View Crematorium to dispose of the cremated remains as fdlows:
Mail to
Other arrangements_Please specify: R t n to Alexander Funeral Home
If pulverbotion of cremated remains is requested,check here X
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.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three worlddays(72 hours)of receipt of the
Burial Transmit Permit and Authorization to Cremate Fes_The cremated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handling 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