Cave, Caroline TO` OY� OF QUEE- BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (� �3 (""t,
Name
— C�tf��ll? �
Case# L�
Date Of Cremation
Time Cremation Started
AM
Time Cremation Completed y4o
Type of Container �o� Cs c,;
Cri
Remarks N fU
M MIN
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Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4475, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name)
(state) (Zip Code)
(Street)
2 cQ t day of 2OW
who died on —�—
at L- _ T—
(place) (Address?
Name and address of nearest living relative or name of pemn authorizing cremation_
�/V'V-
(Name) (Address)
RelationshiO to the'deceased _ -..-• -
Name of Funeral Home. -
IMPORTANT: ,di mmaker,defibrillator or any other batterY operated
I represent that to the best of my kncwtedge,the deceased;has)o- pa
device in his or her body. (Clrcie Qne)
I certify that I have.futl pourer and authorization to arrange fe the cremation or the remains and to direct the disposition of the
gree to protect,defend and
cremated remains,that any personal possessions have either been removed or may be destroyed�kb�Y be made against them
save harmless Pfi?a Viev( Crematorium from any and ail airs and demeracis for°oss or damages
by reason of or crinnected with the cremation of said remains as dirWed,whether such claims or demands are or are not wttgity
groundless,f Ise or fraudulent• q fiA C/D A)1/
(Address)
(Witness) l'2 3- a
1*1-�_ y
f"� ature and Address of Relative or cue'rceprese'tat:re}�
Signed on this date: --
Disposition of CromBted Remains
I hereby direct fine View Crematorium to dispose Of the cremated remains as follows-
(91ark.3nc_
Mail to,--,--- - - - 3IO 5aran`ac Ave.
_ Lake�larid,.NY._-1294a— —
Other arrangements-Pleaseif pulverization of cremated remains is requested.check'"'ern
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 7:00am 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
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 alternate container. Caskets and containers
must be of a combustible material. No styrofoom 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 via Pegistered U. S. Mail within three days of cremation to the funeral home
handling the serJce unless other arrangements are made. There will:be a $30,00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 yeas; $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations (Weekdays) $450-00
Saturday Cremations $450.00