Lomax, James OF QUEEN,5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_(
Name T
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Case# �'l{
Date Of Cremation
Time Cremation Started
Time Cremation Completed 3d
Type of Container tirkr kv4
Cr J - 'j nci .S�
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: (51 a)745-4477
Authorization to Cremate
The undersigned requests and authortms Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
James A. Lomax Male
(Name) (sex)
12 _fairview Ave . , North Creek, NY 12893
(Street) (City) (State) (Zip Corse)
who died on 9 t h day of Oct 20 j L
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Dorothy_ Lomax (same as above)
e
(A ) -
Relationship to the decked Spouse
Name of Funeral Home Alexander FH, Tnse Nprt-h Ri war Nv
IMPORTANT:
1 represent that to the best of my knowledge,the deceased l"Nr(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
1 certify that t have full atrthorFzatiion to arrange for the crema tiart of the remains and to direct the disposition of the
cremated anyr pOssessians{rave either been removed or may be destroyW,and a9ma lo protect,defend and
save Me matariutn from any and all c h*m and demands for loss or damages which may be made against them
by r of or with the cremation of said remains as duected,whether such claims or demands are or are not wholly
g ndiess, or fraudulent.
Warrpnsb
(Whness) ( )
X ;f)L-7 . I>,., Same as above
' (Si re and Ad*iass of Relative or Legal Representwm)
Signed on this date: 10-9-0 6
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify _ F H will n i r-k i i n
if pulverization of cremated remains is rimed,check two 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:
arrangements for the acne QQam 3;3QPm. Prior telephone
necessary for Saturday cremations. remains are neoessary*arrangements are
2. A "Authorization for Cremation"signed by the nearest next of kin is necessary stating
that they do have the power and authcuity to arrange
and to direct the disposition of the �for thhate cremation of the remains
have either been removed may {m''t agreea�per
Possession,
harmless
Pine Vt�rr�ai defend and
d save
for toss of damages which,may e,Y,ands
the cremation of said remains and/or di e agak'st them by °f or connected with
such claims are, or are not ass, of��remains as directed, whether
addition to a regular burial wholly groundless' a or tt tdulaM Ibis authorization in
Permit must accompany the remains
3. All remains must be in a MSUJ-wt or suitable aWmMe
must be of a combustible material. No container.Caskets and containers
styrofoam or plastic containers will be accepted.
�. Cardiac�cemakers,defibn7lators or other battery
before any remains will be accepted. operated devices must be removed
5. Cremations win be comPleted wtthin three works hours)of Burial Transmit permit andng s�2eipt of the
be mailed via Registered d S�wittti tiOn�� ate days of Form.The cremated remains will
handiing the service uric other cremation
to the funeral home
for this service_ are :Tie will be.a$30.00 charge
G. Cremation,Administration Costs and R
Adult ecarding Fees:
Children (age 13 months to 12 y � $$ .QQ
175
ears
Infants (stillbom to 1�: s 8.QQ
Overtime Cremations(Weekda $ 50.00
Saturday Cremations $45Q'QQ
ns
$450.00