Landrey, Calla TOTI/N OFQUEE9�(.50u��y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M13 (-L#RC
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Date Of Cremat G ion
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T 'me Cremation Started 7. 30 /4
Time Cremation Completed `i ,C(o A
Type of Container
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 auftwbms Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remekns of
(Nam) Mex)
/ems r��a �i��rr�i /z� 1AI<,s PLAc la, ,'yiyd
(Street) (City) (State) (ZI6 Code)
who died on 3/ S f day of -"FA'Vci 412. 20- -7
at e'-"i�//,EirJ .c�i'✓L c (�'o t t� l.G'/�AL/JC
( ) (ems)
Name and address of nearest Nft relative or name of person m*wrb*V cremation:
(Name) ( )
Relationship to the deceased PAUGiJrir'/2.
Name of Funeral Nome A-1 C
IMPORTANT:
I represent that to the hest of my knowledge.the deceased(has)or PAV1119pacernalter,de4nrMator or any other battery operated
device In his or her body. (Cirde One)
I certify that I have full power and au trorbmtion to arrange for the cremation of the remains and m direct the disposition of fhe
cremated remains,do any personal possessions have either been reproved or may be destroyed,and 0WISS to protect,defend and
save harmless Pne View Crematorium from any and all cairns and demands for loss or damages w tdch maybe made agenst them
by reason of or connected with the cremation of said remains as directed,whWw such claims or demands are or are not wholly
groundless,false or fraudulent.
(VAI ness) (Address)
(Signaw a and Address of RelWive or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Fate View Crematorium to dispose of the cremated remains as follows:
Mail to /��• /� �'Gi=1/`L/� //r-1 G ,
- t7/Z4 AM r ,S� l/9/lt-' �L�I G iJ N� /� `��
Other arraraxnerts-Please specify:
If pulver¢ation of cremated remains is requested,dm&here `�/•
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 ducted,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 (stilibom to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00