Tonnesen, Stanley u
fin' q+N OF BQUEEN
U-�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
:Name ,
C +CI(I Funeral Director Icx )ne(xr
l� �u ---A_
�►ne5er� Case# 5 3�
Dace Of Cremation
q
Time Cremation Started
Time Cremation Completed 3 / 6
Type of Container C��r; 06.1, T1=
I 15'
Remarks
Main SO �M
X.3 a PH
---------------
--------------
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
The undersigned requests and authorizes Pima View Crematorium,in accordance with and
cremate the remains of: sut ect to its Rules and Regulations to
a s@v Male
(Name) -- (Sex)
Robert,-Gardens North, 220 Weeks Rd. , Apt. #2 , Queensbury, NY 12804
(Street} (City) (State) {Zip Code}
who died on 7 day oiF__ de c e mb r 20_Q�
at Robert. Gardens North, 220 Weeks Rd. , Apt. 2 , Queensbury, NY
(Place) (Aftess)
Name and address of nearest living relative or name of person authorizing cremation:
Dorothy Tonnesen, Queens-buy' NY
(Name) (Address) —" -
Relationship to the deceasedLY�
Name of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the test of my knowledge,the deceased(has) (has no cemaker,defibrillator or any other battery operated
device in his or her body. (Circle one)
I certify that I have fill power and atlthorization to amjnge for the aemsadw of tie remains and to direct the&SPOsition of the
cremated mmalns,that any persorial p oris have either been rernaved or may be degmVed,and agree to ProteCl,defend and
save i>atrrlk--SS Pine View Crematorlum from any and all dahns and demands for lass or damages which may be made against them
by reason of with the cmmrw a of said remains as directed,whether such claims.or demands are or are not wholly
grounise o nt
/r nbiu-,
(Witness) (Address)
Queensbur NY
(Sighfitum and Address of Relative or Legal Representative)
Signed on this date: C/
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
taa'il to
Other arrangements-Please spedfy: R t n to Alexander Funeral Home
If pulverization of cremated remains is requested,check here
Revision:January 1.2006
Policies, Rules and Regulations
I. 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
rem
have either been oved or may be destroyed and agree to�
harmless Piece View Cemetery and Crerr vtorsu n from Bny and 811 laims 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 grmrndless,false fraudulent This authorization in
addition to a regular burl-al permit must accomp�,the resins
3. Alt remains must be in a msket 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 WIN be completed within three working days(72 hours)of
Burial Transmit Permit and Autha�riza*m to Cremate Form. f pt the ated
be mailed via Registered U. S. Mail within three days of cremation to al home
for this service_ remains
handling the semm unless other-arrari�are made.- wilt 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 (stillbom to 1Z,.morrt4s) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450 00