Shave, John OF
QUEE9 5B 1.1 rP�
PINE VIEW CEMETERY AND CREMATORIUM
QUAXER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director_A,, cncte
Fame Jv 54"
Case# �5
Dace Of Cremation
I- �� - 07
Time Cremation Started
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Time Cremation Completed ( U
Type of Container (tirO
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:
Jc n R. S-lave male
(Name) (Sex)
Countryside Manor , Warrensburg, NY 12885
(street) (City) (State) (Zip Code)
who dredar 11th day of Jan. 2D07
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person w4iorizing cremation:
Ronna Brainard, 7 River St . , Warrensburg, NY 12885
(Name) (Address)
Relationship to the deceased niece
NameofFunerwHome Alexander-Baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my w*wMdge,the deoeesed(IWAW(has no)pacemaker,def irillator or any other battery operated
device in his or her body. (Circle One)
I certify that i have full a autl�o bit ion to arrange for the cremation of the remains and.to direct the dtsposit n of the
cremated remalrhsL�f any al possessions heve either been removed or may be destroyed,and agree to protect,defend and
save from any and all claims and demands for kiss or dernages which may be made against them
by or with the aernation of said remains as directed,whether such claims or demands are or are not wholly
fate
-nsbtirg , NY
(Address
i
Same as above
( ' of Relative or Legal Representative)
Signed on this date:
1-12-07
Disposition of Cremated Remains
I hereby direct P'me View Crematorium to dispose of the cremated remains as Maws:
Mail to
00w affarVernents_Please spafy: FH will pick up
If pulverization of cremated remains is requested,check here X
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 remah,that any pal possessions
have either been removed or may be destroyed and agree to protect,defend and same
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,whetter
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 t fie furmMl 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 month to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00