Upton, Nellie r-rO O
P LNE YI E'PY QUEE-�750uT
CEMETERY AND
WAX-ER ROAD, QUEENSB URYCREMATORIUM
, KEW YORK 12804
(518) 745.4476 (518) 745'•4477
Funeral Director 13
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TOWN OF QUEENSBURY U
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
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:
e /""
d
(NAME)
(SEX)
(STREET (CITY) (STATE) (Z1P CODE)
A t
who died on day of 20
t&
at
(PLAC ) (ADDRESS)
-Na and address of nearest living relative or name of person authorizing cremation;
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased Las or as pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization 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
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WTNESS) ( DRESS)
(SIGNA E OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date; z /4-1/0 7
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
i
Ma '_ to
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
the crematorium will be open for, cremations 5 days a wee}: 7 : 0
3 : 30 P .M. Monday-Friday . No Holidays or Sundays ,
arrangements can be made for Saturday . Pre*arrangements b;'
telephone for acceptance of remains is necessary.
�., Pine View Crematorium is
1Tow located of Queensburygrounds of the Pine
_ew Cemetery, Q
3 An authorization for cremation properly signed by the neares�:
next of kin or other authorized person 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,
-nat any personal possessions have either been removed or may b
d stroyed and agree to protect, defend and save harmless Pine
ms and demand for loss of
rematorium from any and all clai
iTages them by reason of or connected
which may be made against
the cremation of said remains and/or disposition of said
as directed, whether such claims or demands are, or ^'
r. r "holly groundless, false or fraudulent . This authorizatio:
iti.on to a regular burial permit must accompany the remains .
All remains must be encased in a casket or suitable alternate
container . Caskets and containers must be of combustible
material . No Styrofoam or plastic containers will be accepted .
5 . The question relative to cardiac pacemakers must be answered
or. the authorization to 'cremate form before the remains will be
accepted.
r , Unless other arrangements are made the cremated remains will
be mailed via Registered U . S . Mail within three days of cremation
to the funeral home handling the service . There will be a $25 . 00
charge for this service .
remation, Administration Costs and Recording Fee : Adult $300 . 00
h. 'dren (age 13 months to 12 years) $150 . 00 Infants (stillbDr!�
0 12 months) $100 . 00
Additional $100 . 00 charge for cremations done after 3 : 00
P • . •
^nday through Friday. Cremations done on Saturdays will !"
'r.arged the additional $100 . 00 Any remains received after 3 , 3=
Mori-Fri or Saturday will be charged an additional $100 . 00 .