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Perry, Phillip OF QUEE9�SBUj \y PINE VIEW CEMETERY AND CREMATORIUM WAXER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745.4-476 (518) 745'.4477 p Funeral Director Fame Case# — I/ e Of Cremation a<<� me Cremation Started -7: j T ., Te Cremation Completed 101106 I'1 ' rPe of Container rC � C Y� w 00- '�- IS S Remarks ©�� 0 AN q:oo �( -------------- ------------- I I i I i i i I //57 Town of Queeresbury 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.end authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: -e---------- Sex) _fALLI, L (Name) ( (City) (state) (Zip Code) (Street) day of 20—07-- who died on at jam (Address) Name and address of nearest living relative or name of permson authorizing cremation: (Name) (Address) Reht!6n§hi0 to the'deceasbd Name of Funeral Home IMPORTANT; k7��QaM1 maker,defibrillator or any other battery operated t represent that to the best of my device in his or her body. (Ckcle I certify that I have full power and authorization to arrange fir the cremation of the remains and to direct the disposition Of it'(.- p proted�defend and cremated remains,"any Personal possessions have either been removed or may be destroyed,and agree to d nd save hgMiess pine v*W Crematorium from any and al,claims and demands for less or damages which may be made against the") -aid remains as dirWed,whether such claims or demands are or ate not wholly by reason of or connected with the cremation of., groundless,false or fraudulent. All"�2 (Address) 2-3&' (Signature a4 Address RepreserIative) Signed on this Disposition Of Cramaled Remains I hereby direct Pine View Crematorium 10 d#.V- a e We e I t d remains as follows: 231 84 Mail to ra MA "Ni—i6, NY 12946 Other arrangements-Please specify'—__—, If pulverization of cremated remains is requested,cnel&i-ere • 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 suAable 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 to removed before any remains will be accepted. 5. Cremations will be completed within Three wo iking 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 (stillborn to 12 months) $125.00 Overtime Cremations (Weekdays) $450.00 Saturday Cremations $450.00