Colby, Phyllis TO rNN OF QUEE BU_(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I Funeral Director �i3 CLc��K
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Date Of Cremation G
Time Cremation Started
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Town of Queepsbury
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 Pine View Crematorium.in accordance with and subject to its Rules and Regulations to
cremate the remains of:
PHYLLIS COLBY FEMALE
(Sex)
A L PLAC ID-t—AY-1-Z 9-4-6
(City) (state) (Zip Code)
who died on 11th day of DEC EMBER 2C
at AMC @ SARANAC LAKE
(Address)
Name and address of nearest living relatfre or name of person authorizing cremation:
MRS. SHANR St LOUIS 70 GREENWOOD St. , LAKE PLACID, NY 12946
-'(Name) (Address)
Relationshio to the,deceased N E I C E—-----
Name of Funeral Horne M_ B_ CLARK, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have.fUll power arid,authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions hove er.her been removed or may be destroyed,and Wee to protect.defend and
save harmless Pine vwvi crematorlum from any and all clairris and demands for loss or damages wtilch may be made against them
by reason of'br c6nnetted wfth the cremation of said remains as dirWed whether such claims or demands are or are not whofty
groundless,1 or fraudulent.
131 5ARAX9 C NYE _LAKE.-PLACID, NY 12946
{Witness) (Address)
70 GREENWOOD ST. , LAKE PLACID, NY
(Signature a A ess of Relative or,ega Represe^tative)
Signed on this date: D E C E M B E R 112 , 2006
Dtsposjtjon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the co.-mated remains as follows:
Mail to M. B. CLARK, INC.
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Other arrangements-Please specify: ......
if pulverization of cremated remains is requested,check"ere Xx------
Revisiow January 1,2006
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Fine 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
necessairy 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 bp-. made against them by reason of or connected with
the cremation of said remains andfor 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 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 Via'Registered 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 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations $45C-00