McDonald, John L O OF QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 3 C 1se
Name �1e�n c �,t; tll Case# 3�
Da to Of Cremation_
Time Cremation Started I .' ') & AM
Time Cremation Completed I t,, )
Type of Container_ Cc,rdka,',rd LE is �s �_
Remarks
2 �'
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 r and authorizes Pine View Crematorium,in accordance with and sub)W to its Rules and Regulations to
cremate the remains of:
VA cA (Sex)
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who died on _ _�". .: day of `_ � 2O°k
at ( )
a!
Place}'
Name and address of nearest living relative or name of person auomwizing cremation:
I QTH� _ 4— <<�S ao/L�
(Name) (Address)
Relaw5riship to the deceased_
Name of Funeral Home --
IMPORTANT. 2310 Saranac Ave. L 14F /0444 ar/Y
I represent that to the hest of my knowledl�14)Atie��s)1gC9r4�3nQ)P am, arty o#w battery operated
device in his or tier body. (Circle One)
I certify that d have;fuN power and authorization to arrange for the cremation of the remains and to direct the.disposition of the
I have either been removed or may be destroyed,and agree to Protect,defend and
cremated remains,chat any Persona m ftM possessions Watch may be made against them
save harmless Ptrits VieM+Crematorium isotn any and atl claims and demands for loss or damages
by reason of cortrieded with the cremation of said remains as drregled,whetter such Mims or de rnands are or are not wholly
groundless,false or fraixk9ent.
S) (Address) ,�p
and A of R lattve or Legal Repress owe)
Signed on Is date: O -
OIsPosnm of Cremated Remains
I hereby direct Pine View Crerrmforium to dispose of the Cremated remains as follows.
Mail to_ __.----.---..__ _._ 0A•S•ftrk. --
M310 8asanac�ve.
bake --._...—.-.�._...�.--
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:Januaty 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 end Crematorium from any and all claims and demands
for toss 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 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
handlinb'the service unless other arrangements are,mar)e'. 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 (stilibom to 12 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00