Horner, Sara LM+N OF QUEEN,5BUTr
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4477
C I Funeral Director_ nt5 C( ( k
Name �aCh rl ofner
—Ca se# 5-2
Date Of Cremation -pt
Time Cremation Started s
T :me Cremation Completed 5 . f (y
17
Type of Container r oArcY '
Remarks
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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:
(Name)
U111. 1J�i Elz _C%/z /cc= t/}ciA �N� /Z�i4�G
�l
(street) (City) (State} (Zip Code)
who died on
day of�_`�—____. 20Q�?
ice, ,_.___..—._�._..-----.--- --'
at
(P1ace) (Address)
Name and address of nearest living relative or name of person mithorizing cremation: ����a C / J
rY) r�Ccc `3 ,�� h-L- rn u-'��� i 11 _— -
(N� (Address'
Name of Funeral Nome
IMPORTANT:
{represent that to the hest of my knewiedge.the deceased;ryas)or has pacemaker,defibrillator or any outer battery operated
device in his or her body. (Circle One)
certify that I 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 beers removed or may be destroyed,and agree to protect.defend and
save tee r m inine at a Crematorium froth any and asi cairns and demands for loss or damages which may be made against them
by reason of or conneiXed with the cremation of said remains as dire4ted, her such claims or demands are or air'not wholly
grot ndlessytplse or fraudulent.
2310 SARANAC AVEt, ,LAKE.,.-_PLACID, NY 12946
(Witness) -C
) — -- ;address) C�
-- -- ---- ,
x__.__......._�tgnd Address of Relative or ega:tieprese native).. .JoZ /
Signed on this date:-_)—( /a -a----.-E•o(0
Disposition of Cr2snated Remams
I hereby direct Pine View Crematorium to dispose of t;rf ciernated remains as follows:
Mailto M. B. CLARK, -
_ 2.3-10 5ARAN&C_-.P�V�,_..�A��__PIAC-ID11-.�tY_12246.---.-
Other arrangements-Please sPe&7:
if pulverization of cremated remains is requested,ci"e-4,rare_XX
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 arnange for the cremation of the remains
and to direct the disposition of the cremated rernains,that any personal possessions
have either been removed or may be destroyeo,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 ageinst them by reason of or connected with
the cremation of said remains andlor(-1,!1Wsiuon 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 ac�mpany 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 withinthr;—:-e woriking 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 Nvithin three days of cremation to the funeral home
handling the seviice unless other arrangements are made. There will,be a $30.00 charge
for this service.
6. Cremation, Administration Costs anid ?,,ecording Fees:
Adult $325,00
Children (age 13 rnonths to 12 yearn! $175.00
Infants (stillbom to, 12 months) 25.00
Overtime Cremations (Weekdays) $450.00
Saturday Cremations