Shaw, James OFQUEEN50Ur
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745'-4.477
Funeral Director f
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Date 0 ( Cremation
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)74SA476, 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
James E. Shaw Male
(Name) (Sex)
3 Barton Mines Rd. , North River, NY 12856
(Shee) (City) (State) (Zip Code)
who died«r 13th day of. Feb. 20 07
at his home (Same as above)
(Place) (Address)
Name and address of nearest rMN relative or name of person artthorbft cremation:
Judith Shaw 3 Barton Mines Rd. , North River, NY 12856
(Name) (Address)
Relationship to the deceased Spouse
Name of Funeral Home_ Alexander FH, Inc, North River, NY
IMPORTANT-
I represent that to the best of my lonowk4ge,the deceased( r(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle one)
I cm* 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
ounated remains,that arty pe�na�ssions have either been removed or may be destroyed,and agree to protect,defend and
save harmless �/krw Cre um from any and all claims and demands for loss or damages which may be made against them
by rmson c�rvrecled�cremation of said remains as directed,whether such claims or demands are or are not wholly
.false or
Warrensburg, NY
!
(Address)
Same as above
(Signature and Address of Relative or Legal Representative)
Signed on this date: 2-13-07
Disposition of Cremated Remains
I hereby direct Pine Vow Crematorium to dispose of the cremated remains as follows:
Mail to
other arrangements-Please specify: 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 r+errtains are necessary.Prearrangements are
necessary for Saturday cremations.
2. A `Audxxtm*m 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 dint the disposition of the cremated retrains,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 frauduleft 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 c rarnation to the ftxreral 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