Walker, Joan �O 097
PINE YI E`FY QUET:g�fu�BuTry
CEMETERY AND
QVAK.FJt ROAD CREMATORIUM
QVEENSHURY, NEW YORK 128o4
(518) 745.4-476 (518) 745••4.477
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
-Z04A/ M , W I l O(L y
(Name) (Sex)
51 Al' Mi,.jCYCV4 A fzFr/
( ) (may) (stare) (Zip cam)
who died on / day of_4X—1 L 2oo-7
a< 10 7�.- �� N l �utvlli� r'
'(fie) (Address) �
Name and address of nearest riving relative,or name of person authwb*V cremation:
(Name) Address)
Relationship to the deceased 5"15%t3 e
Name of Funeral Home O1.-C
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defrbroator or any other beaary operated
device in his or her body. (Cirde One)
I My that I have full power and author¢atton to arrange for the cremation of the maim and to direct the disposition of the
cremated nernaft,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View-Cremitodift ftgm any and all claims and demands for loss or damages which may be made against them
by reason of "-r octed with the csernadon of said remains as directed,whetter such claims or demands are or are not wholly
groundless;false or fraud 14M
/ (Address)
(Signature and Address of Restive epresentative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangerretnts-Please specify: �H Wow �, P
If pulverization of cremated remains is requested,check here N-1_
Revision:January 1,2006
PO
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 acoeptartce of remains are necessary.Preenangements are
necessary for Saturday cremations.
2. A `Authorization for Crermfion'signed by the nearest next of kin is necessary stating
that they do have the power and authority to arrange for the cr�emabon of the remains
and to direct the disposition of the cremated remains,that any persona
have either been removed or may be destroyed and agree to protect,defend and same
harmless Pine View Cemetery and Crematoriurn 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,wte#w
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 Fort.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