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Potter, Susan TM� OF QUEEN,5BU-r)�y P'NE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSgURy. NEW YORK 12804 (518) 745-4476 (518) 745.-4-477 Funeral Director /�[�u�h Name 5C,n �cRer C a s e# Ll Dace Of Cremati.on 11- i3 -- Olr, Time Cremation Started qp Time Cremation Completed ; ©O Type of Container e,, ��c,�c�► _ Remarks mql► 50 I� ao k h I i f 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 autiwrizes Pine View Crematorium,in accordance with and cremate the remains of subject to its Ruffs and Regulations to __ S,usan M. Potter Female 1187 Friends lake Rd. , Chestertown, NY 12817 (Street) (City) (State) (zip Code) who died on 11 t h day of Dec. 20 06 atAlbanv_ Memdical Center,_ Albany, NY (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Thomas C. Potter (same as above) (Name) (Address) Relationship to the deceased H u s b a n d Name of Funeral Home Alexander-baker FH,Warrensburg, NY IMPORTANT: I represent that to the best of my knowledge,the deceased(KAMI)as no)pacemaker,defibrillator or any other battery oeraled device in his or her body. (Circle One) p 1 certify that t have AS power andMAWFUaWn to arrange for the cremation of the remains and to fixed the disposition of the cremated remains,that any Personal POSSBwkns have either been removed or may be destroyett,and agree to protect,defend and save harnttm Pine V*W-Cmmatorium from any and all daims and demands for loss or damages which may be made against them by reason of or cQ011GEted with the cremation of said remains as directed,whether such cdalms or demands are or are not wholly groundless,faldbe or fratrdulen+ Warrensbur gA Y ) X �-rvtt.-t a /A_SaMe as ffis above (Srgnature and Address of ReWwe or Legm Represemajive) Signed on this date: 12-1 1 -0 6 Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows: Mail to Other arrangements-please specify: F H will pick up if pulverization of cremated remains is ram,check here X Revision:January 1,2W6 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 3.30 arrangements for the acceptance of are - pm. Prior telephone necessary for Saturday cremations. �'P�mangements 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 rernairrs and to direct the dim of the have either been removed�may destroyed �,that any Donal pions harmless Pim View Cemetery and Cre �#Mn ny and all to dam and demands save for loss of damages which may be madeands the cremation of said remains and/or d' them by wort of or connected yy� such claims are, or are not whop disposition©f wins as directed, whether addition to a regular burl y gu��' false or fraudulent-This authorization in permit mast accompany the rrrmaims 3. Ali remains must be in a casket or suitable an must be of a combustible material. No am or container.Caskets and containers Styrofoam or plastic aontalners will be accepted. 4. Cardiac pacemakers,defibrillators or other bats ery operated before any remains will be accepted deices must be removed 6. Cremations will be 00mpleted within three wfting �72 hours reaei Burial Trransmk Permit and Authorization , } pt of the be mailed via Registered U. S. Mail within threea s a�matron to the funeral home The cremated remains w!I handling the service unless other arrangements are made.There will be a$30.Op urge for this servka_ 6. Cremation,Administration Costs and Recording Fees: Adult $325.00 Children (age 13 months to 12 years) $175,00 Infants (stillborn to jZMorrths 00 Overtime Cremations(We4 $t25.00 Saturday Cremations $450.0 $4500