Lynch, John OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A(r� �j
Name Case#
Dace Of Cremation YA ��. c�
Time Cremation Started A H
Time Cremation Completed lu
Type of Container j �, {hac rrG 1CG t ST CA t7
Remarks
H
v
31;5
Town of Queensbury
Pine'Jiew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 128o4
Cemetery Office-, (5i8)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned reams and authorizes Pine View Crematorium,lo accordance with and
cremate the remains of Subject to its Rules and Reguiations to
--John Lynch Male
( ) (_Sex)
John Earl Towers , Apt #8F Hudson Falls , NY 12839
(Street) (City) (Sfate)
who died on 9 t h f,of Aug. _20 0 Code)
at Glens_ Falls Hospital _
(Placi) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Joan Quellette, 6 Theresa James St . , Warrensburg, NY
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Alexander-Baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(fU$r(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle one)
I certify that I have full power and autivrixaticrri to arrange for the cmmatfort of the remains and to diced the disposNion of the
cremated remains.thatEft
sonar possessions have edhw been ren►oved or may be d�o'yed.aria to ,deferW and
save hamrtess atorium fnxn any and aN claims and demands for loss or damages which may be made against them
by rea #te r�errretion of said remains as directed,whether such claims or demands are or are not wholly
9ro fratrdui
W
arrensburp, NY
Maness) (Address)
Same as above
(Signature and Address of Relative or Legal Representative)
signed on this date: 8-9-0 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: F H w i 11 pick up
If pulverization of cremated remains is r requested,check here
Revision:January 1,2006
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.Tine
"matorium operates Monday through Friday from 7:O0am to 3.30
arrangements for the acceptance of remains are pm. Prior telephone
necessary for Saturday cremations, necessary.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 dim of the cremated
have either been removed or �'#ratee toY P Pions
harmless Pine View Cemetery arxl�Csernat yomed 8W� ajPUWims adef
nd anmsave
a
for loss of damages which may be made against them by 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 acmnpwy the temains.
3. A!!remains must be in a casket or suitable altenrate
must be of a Styrofoam or combustible material. No fir.Caskets and containers
plastic containers will be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
I. Cremations will be CompletW within three
Burial Transmit Permit and �days� �'� Of the
be mailed via Registered U.S. Mai within three day,o Cremate Foffn.Thecxemated remains will
handling the service unless other arrangements are cremation to the funeral home
for this service. -one will be_a$30.00 charge
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stilibom to t2:A)W*)s) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 00