Burnah, Marvin r'n`NIN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ( CLQK
\ame ctf V�h
Case# L iD
Date Of Cremation
Time Cremation Started 1: 10
Time Cremation Completed
Type of Container pkry r�N, ur� T GptS
Remarks
6
s
• Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12804
Cemetery Office:(W)745-4476, Crematorium: (518) 7454477
Authorization to Cremate
The underslgrled re*,esit and authoriz5es P'me View crematorium,in accadanre with
AM subject to its Rules and Regulations to
cremate the remains of M I+L e
a
Lo (-,M DA Lam-
��� (Stale) CAP Oode)
who died on __ / t --- day of - eL
�d r !c i=DJe�t_ e1V7A - SA6t -�e/�e c Y
at (Place) (Address)
Name and address of nearest riving relative or name of person authorizing cremation.
At Y
Name} (Address)
RelatidrsshiEr{o ttie deceased�.. S 1.$ �� - — Fir nt. —'.�
• Name of Funeral Hone — Lake Placid, NY 12946
IMPORTANT:
I represent chat to the hest of my Iv►o>w+ied9e, wrs the deceased(has)or �Pacemaker,SOT or any other Wary opera{ed
device in his or her.body. (Circle one)
1 certify that a have full twvsrer and atRhOrlZetiOr►to arrange eitFBr been removed may�remains��,and agr'ee�itea the
detend and
cremated remains,that a.�r personalpmessi°��have
an and demands for bss or damages VA*b may be,made against them
save tearmless pk a VteNi Crertratorium fiotn any
by reason ator connected with the cremation of said remains as directed,whetter such claims or demands are or are not wholly
groundless,false oar fraudulent. G
cr L1�_ .i_G -YL (Address)) r��1 c�4 ��! �29 v
(S LA
ture and Address of Relative or Legal ftepreserriative}
Signed on this date:.—al-
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to d of the cremated remains as f0lims;
• M.S. ( lark.Inc. .- -
Mall to
Lake Placid,
Other arrangements-Please specify: --------
if pulverization of cremated remains is requested,check here '
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 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday crernations.
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 all 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 aftemate 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 receipt of the
Burial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed "vie,Reglstered U. S. Mail within three days of Oremation to the funeral home
handliriOM service unless other arrangements are made. There will,be a $36.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $450.00