Hertzner, Kenneth LOr IN OF QU EE
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENsgURy, NEW YORK 12804
(518) 745-4476 (518) 745'-4477
Funeral Director_A Jrr
Name KPnnCtL I-fQr+ ner
Case# L14j �-
Date Of Cremation _
Time Cremation Started I ' C %
Time Cremation Completed
Type of Container
Remarks
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30o
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematortum: (518)745-4477
Authorization to Cremate
The undersigned requests and aulbottms Pine View Crematorium in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Kenneth Hertzner Male
--(Name) (Sex)
(Street) (CTmI) (State) (Zip Code)
who died on 3 r d day of Nov 20 06
at 189 Baton Mines Rd. , North River , NY 12856
(Place) (Address) -
Name and address of nearest living relative or name of person authorizing cremation:
Alan Hertzner, 189 Barton Mines Rd. , North River, NY 12856
(Name) (Adder) -
Relationship to the deceased S o n
Name of Funeral Home Alexander FH, North River, NY
IMPORTANT:
I represent that to the best of my k rmwledge,the deceased M Fr(has no)Pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
!certify that l have fun power and au"WrbMtiore to&range for fhe crerrmtiare of the rem and to direct the disposition of the
cremated remains,00 any personal Possessions have either been removed or"be destroyed,and agree to proms,defend and
save harmless Pine View Ste+ txtt from any and all claims and demands for foss or damages which may be made against them
by reason of or. a the cremation of said remains as directed,whether such claims or demands are or are not wholly
ground s uduk0L
+ Warrensburg, NY
ness) (Address)
s above
(Signature and Addy ive or Legal RepreserttaCsve)
Signed on this date: 1 1 -3-0
I
I
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other ---
arran gemenLs-P spedfy: F H w i l l p i c k up
If pulverization of cremated remains is requested,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:O0am to 3.
arrangements for the acceptance of remains are � . 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 nenai a that any
have either been removed or may be destroyed and personal ions
efend and save
for
Ptcte View Ceittetery and Cremato"M from��s SH daims and demands
for foss of damages which may be made agmte
ainst 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 a addition to a regular burial permit must accompant the emains.
uthorization in
r
3. All remains must be in a msU&l or suitable ahemate container.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers,defibrillators or other bats
ery before any remains will be accepted. operated devices must be removed
5. Cremators WM be compietol within three working days(72 hours)of receipt of the
Burial Transmit Permit and AMOXWbMion to Cute Form.
The ated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handiing the service unless other-anangeMents are made-Theme will be a$30al home
for this service. charge
6. Cremation,Administration Costs and Regarding Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12-rx> ) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00