Stone, Thomas L O'Y N OF QUEE 5BUP�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEF_NggURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
15 c.
Name �rnc,S �J+on .,
Case# (�li
Date 0f Cremat ' Q - �0 ._ U(,,
Time Cremation Started
1� 3�
Time Cremation Completed � ` t(o ?(I
Type of Container grcl uc„��
Remarks
M TN
�'Ou ,sty
-0c) .ctoell
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 Pine view Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
1 f�;<�i��a S J rc�•t,�T /vl/11 L,c
(Name) (Sex)
w/Tsn� S%�r`�'T GG�ffi%Fi`f.9�/ /�/ 7
(Street) (City) ( e) (Zip Cam)
who died on /Cf.. - day of 20 ,�/ L
at L'l&', f�a'� A14 Ra"rlt�/ �+-/f� �L i�i�5 `,g Ll s N<'w
(place) (Address) /
Name and address of nearest living relative or name of person authorizing cremation:
*7
(Name) c (Address)
Relationship to the deceased /L 4 k G 6 ;;�'X
Name of Funeral Home
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 1 have full power and authorization 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 Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
undless,false or fraudulent.
7
-Tz 2-
(witness) ` ( )
(Signature and Address of Relative or Legal Representative) W h { c;k
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here L�
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:OOam 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 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 service 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 $450.00
12/19I2036 13:05 5iB4991050 •JILLSON FUNERAL HOME PAGE 01
Town of QueertSbury
Pine View Cemeuwy and CrenuwAurrl ( 1
21 Quaker Road, Queenabury, New York, 12804
Cemetery 4(fim:(518)745-4476,Cternatorfum: (518)745-4477
Authorizellon to Cram fm
The undersiprml ratWaats and&Axwimes Phe view Crametor tm,in 6ocordw=whh and mks o t to Its Rules and Regulations to
ohvmeie"I"Iftina af:
f 117"-VM,9
(Norm)
(street) (Cky) (State) (Z Code)
who died on ._ r C fr day of b C�•+�e 20Q,b
et 4_ oyfr'•r f AI 00.s1'e6l/141y w G ns ,�r t[ /l.�Piw (/e
(Piece) (Addess)T-
Name and address of nearest llvrhp rsiaMve or none of pereel ahehorkft oremation:
(► �) (Ad )
Rgietbrehip to the daoeeead o vi .a., /L.0 4 G 40 V-k
Nsrrhe of Funeral Hans ��i`S UK ��hf�.r-t~ r7`D�P �G
IMPORTANT:
I rsprow that to dm beat of my ItrhovAedge.ma decetigd(has)or More)pecenhmloer,daAbdllator or any othw befty operated
device in his or her body. (C"One)
I car*Thar i!rare till pcmw and sulhorbe*m to onarw for the aemwJm of the ramarha and lo direct The dimmusitim of the
aarnaled remains,dial any personal pome iao haw efdter ban removed of may be deetripM.and apse to Drole 1, deiand and
save tternhlasa Pile view Cmmmmkm them any and all ofeYsa and deaw4s fnr bee or daring,1 which may be erode aW&W them
W hbeeon of or amnsoed wkh the conMbn of Bald r w Wm as dieaad,vJ00 0r such darns or derrrerla we or we not whopy
Islas or talld tv-
(Wknon) (Adrk'ea)
( {Slpnahae and Address of Relative or T.epd R oolve)
SWW on this dote:
Disposition of Caamated IlWakv
I hereby drect Ptrq Visw Cmwd*rf"to dispose of the aanded remphb as ldbrrs:
Map to
09W enargenw+Fs-Plasma spedty:
If ptThr9 Wdion of"noted rerrh"is requested,deck hers L!
Rw sW,,danuahy 1,2T)OTf