Jones, George TOrNN OF QUEE9�5OUpy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QVEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745'-4477
Funeral Director t3 C1"y
Name
Case#
Date Of Cremation
T ,me Cremation Started
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T .me Cremation Completed j? l d
'ype of Container
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Remarks
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Town of Queensbuty
pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518) 7454477
Authorization to Cremate
The undersigned reiiiiesti and authorizes Pine View Crematorium,in accordance with M4 sr
to Its Rules and P,bgulations to
cremate the remains of:
GEORGE F. JONES�_� (sex)
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__�-(Harr )
135 PARASIDE DRIVE LAKE PLACID. NY 12946
(Street) (City) (Skate) (Zip Code)
23rd . dayof January�� _ _�7
who died on — -
PLATTSBiJFGH. -NY
at____CV/PH MEDICAL, CENTER,R, P
(P ).
Name and address of nearest 1"relative or name of Person su"N'zing cremation:
DAVID JONES 114 (GGRE-ENWOOD ST. , LAKE PLACID, NY 12946
(Name)
Relatimshio to the,deceased- BROTHER --
Name of Funeral Home
M B CLARK INC LAKE PLACID, NY
IMPORTANT:l represent that to the hest of my knowledge,the deceased(has)or(has no)pacemaker,deice aY other b8tt9ry operated
device in his or her-body. (Circle one)
ect the
I certify that i have fills power end.amhorbation to rr either been rnge for emoved may beon of the
the cremation of the �ddestroyed.ns and to and Wee to tom.defe and
cremated remains,that any Persona P Of1$�al claims end demands for loss or damages racy be made against them
save harmless Pixie View Cf ematodum horn any such claims or demands ere or are not wholly
by reason of"or cdniiected wilt►the cremation of said remmns as d'verAed,whetter
groundless,false or fraudulent.
lX- A #! ) saranac ave. , lake palcid, ny
(Signature ar23
tide or t••ega'!t�epreserriaiive)
Signed on this date:- J A 0 0 7 -
Disposition of cremated Remains
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows'
Mail to -
_ .__.
other arrangements-Please specify: r-a 1 1d—f n r bY—f nn-era-1d�t or
if pulverization of cremated remains is requested,ci*&here 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 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 remover)
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 ft stered U.S. Mail within three days of cremation to the funeral home
handlino`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