Kaszubski, Arthur T0q4N OF QU EEN5BU
,9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name T H UZ KA5Z.0 3 S K.i, Case#
Date Of Cremation �1 - )q - o�
Time Cremation Started be, A N
Time Cremation Completed
Type of Container (_'GrAc,arj CCtiu-f G.'o 7!�T CA�>t_
Remarks
NATO Ad MCvE Am
0n
Cuc,fCIO-,
Town of Queensbuly
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbuty, New York, 12804
Cemetery Office: (5-18)745-447t3, Crematorium, (518)745-447 7
Authorization to Cremate
The undersigned requests and author fare v�Crematorium, accordance with and
cremate the remains of subject to its Rules and Regulations to
— Arrhiir_Kasziihsk; Male
(Name) (sex)
273 Osprey Lane, Flagler Beach, FL 32136
(Sheet) (City)
(state} {Zg Oode)
who died on 21 day of August 06
20
at Glens Falls Ho 1
(Place) ( r�ess)
Name and atWress of nearest living relative or frame of person authorizing cremation:
_Barbara Kaszubski Fl ler Beach, L
(Name) (Address)
Relationship to the deceased S o u s e
Name ofFunera Home�Alexander-Baker Fr,nAr Hnma
IMPORTANT:
I represent that to the best of my knowledge,the deceased�fKzt� (has no makes,defibrillator or
device in his or her body. (Circle One) ' !!�� any other battery operated
i Certify that t have fun power WW authortmWn to arrange for the cremation of the remains and to direct the disposition of the
cremated n mmns,that any persor>et possessions have either been removed or
save harmless tyre View frorir ally and all tairrrs and dew for loss Or damages hich and agree to Protect,defend and
by reason()f. Cremation of said remains as detected,whether such or may be made against ysem
groun¢tesss,false dx demands are or are not wholly
(VvftrleA) (Address)
`� Fla lei Beach FL
(S' a and Address of Rehire or Legal Represemative)
Signed on this date: 0 8/2 2/2 0 0 6
Disposition of Cremated Remains
I hereby direct Pixie View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please sped3ty: R t n to Alexander-Baker Funeral Home
If pulverfzatim of cried remains is rimed,check here X
Revision:January 1,2W6
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Fly from 7:00am to 3.30
arrangements for the acceptance of remains are necessary.p a• Prior telephone
necessary for Saturday cremations. Prearrangements
are
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,tlg any ! ions have either been removed or may be destroyed anti to harmless Piste View Cemetery and Cremataritsm#som�an�y and a�claims and demdefend and ands
ve
for loss of damages which may be made against them by reason of or
the cremation of said remains andtor d' connected with
such claims are.or are not whoa disposition of said remains as directed, whether
addition to a nd�'fade or fraudulent. This authorization in
regular burial permit must accomp®ny the remair>,s,.
3. All remains must be in a casket or suitabk.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 win be completed within three
Burial Transmit permit and ��� )Of�o of the
Authorization to Cremate Form.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.
for this service. There will be a$30.00 charge
&. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 1Z,months) $725.00
Overtime cremations(Weekdays) $450 00
Saturday Cremations $450.00