Rollier, James ""'WN OF QUEENSB2:1
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
.Funeral Director ('L��
Name I me Jc�rnc � 1�41„cc Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed 11" '3 ,
Type of Container `�;, � �i �r r �a -�< < :� ,�T CAST
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) 745-4477
Authorization to Cremate
T{1e under lgried regtiesis and authorizes Pine View Crematorium.in accordance with 6d subject to its Rules and Regulations to
cremate the remains of:
J AME S F_-_R QLLJ F LE—._.MA _
_ ---(Nor (sex)
3 VILLAGE PARK LAKE PLACID, NY. 12946
_.._ (Street) (City) (State) (zip Code)
who died on
7th dayof. AUGUST 2o06
3 VILLAGE "LAKE PLACID NY 129,46
AGE PA .�._.._._..
at (Address)
(Place)
Name and address of nearest living relative or name of Person autho"cremation:
MARGARET ROLLIER 3 VILLAGE-,PARK, LAKE PLACID, NY
—�(Name) (Address)
M. B. CLARK, INC. , 2310 SARANAC AVE. , LAKE PLACID
Name ofFuneraiNome
IMPORTANT: the deceased(has)or Lh�)pacemaker,door or any other battery operated
I represent that to the best of my knowledge,
device in his or her body. (Circle one) dired
I certify that I have:fuq power and.authorbatton to ns ancl to
have ee�r been removed m�he cremetion of the iddestroyed,and agree to pr tion f the
and
cremated remains,that any persona possessions for loss or damages which may be made agairust them
save harmless Pirie View Crematorium Holm any and all dolma and demands
by reason o'f"or t:oi'r*ded with the ownstion of said rerr+ei>�as��,whether such claims or demands are orate not wholly
groundless,fqIse or fraudulent.
2310 SARANAC AVE. LAKE PLACID, NY
�— (Address)
ILLAGE PARK, LAKE PLACID, NY
(S tore and Add of a or Leget epresentaUve)
AUG. 9 , 2006
Signed on this dale:._ — —
Disposition of Cremated Remains
i hereby direct Pine View Crematorium to d of the cremated remains as faitows:
Mailto__M•_._B•_CLARK, INC-
2 3 LCL SARANAC AVE LAKE-.PLACID.., NY _._._-12 AC2 -
Other arrangements-Please specify: -----
if pulverization of cremated remains is requested,d*&here X,x
Revision:January 1,2006
r
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 ail 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 working days(72 hours)of reeeiOt 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 c!rematlon to the funeral home
handlihoo'the service unless other arrangements are-made. There wile 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 (sUllbom to 12 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00