Kaltenbach, Mary OF QU
YI
PLNE `J
EW CEMETERY AND CREMATORIUM
QU&XER ROAD, QUEENSBURY, NEW YORK 128D4
(518) 745.4476 (518) 745'.4477
Funeral Director 13 Cup
Fame
Case#
0 ( Cremation
/TV r, I G
�6007
,me Cremation Started
' • me Cremation Completed
� � Pe of Container _
Cw5
Remarks
I� vS
ov,_ 16
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 tndersigrred requests and autltorew Pine View Cremato►ium,in accordance with and subW to its Rules and Regulations to
cremate the remains of
(W
/$S dLn M1,I'MIZY 12-1) LAAxg f LAO AD 1V11 /-;?,rlq�
(Street) TiY (CRY) (State) ( Cam)
who clad �Zza 2002
( ) (Address)
and address Of re or of person authorki g aemedon:
(Name) ( )
�•� �iu wry, k N , Al
Reledonship to the deceased 3Au�SNT��
Name of Funeral Florae_/��- �.3 �L,hi!?�C ING
IMPORTANT:
I represent that to the best of my Ivrowiedge,the deceased(has) defy Uslor or any other battery operated
device in his or her body. (Circle One)
I cer*drat 1 have full pwrar and audwrization to arrange fordo aeawdon of the nsinaMts and to direct the disposition of the
awneW remains,that arry personal possessions have either been ro noved or may be destroyed and agree to protect,defend and
Sawa heerrless Pine View CrenretorNrm from arty and all dalrns and demands for loss or damages wMch may be merle against#Ism
by reason of or connected*0 the cremation of said r alywh s ear dratted.whether such dairrs or detrranda am or are not wholly
groundless,false or fraudulent.
4 4&-e A.4cj*.V
( (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: eq�lZ/C
Disposition of Cremated Rernaft
I hereby direct Pine View Crematorium to dispose of the cremated remains as Maws.
Mail to __/7�(• 4)• e404,reA J�"4C .
Other arrangwonts-Please spedry:
If pulveftetion of cremated r+e ffoirs is requested,check two
Revision:January 1,2006
s
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
Prearrangements are
arrangements for the acceptance of remains are necessary. Prearra p
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 Vlew 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 aRemate 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 h f funeral
charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $325:80-- 3 3v.vv
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.Q0