Lockwood, May OF
PINE YIE QUEE9\�50Uf`y
W CEMETERY AND CREMATORIUM
QUA3CPJt ROAD, QUEENS9URY, I'MW YORK 17804
(518) 745.4-476 (518) 745••4477
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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)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and a uttweas Pine View crernstorium.in accordance with and subject to Its Rules and Regulations to
cremate the remains OF.
.MA V
(Sao
(SW") (Ir) (Slate)' (Zip Code)
who died on day or A btl Le 20�
a<�(�`/)ol�ti wR y , Z-A/< ' A-A
Name and address of nearest oft relw n or name of Person newrtdng cremation:
,A__ Z/) _i 0c1(r1y6)6>0 &IV-grO
(Name) ( )
Relationship to the deceased
Name of Funeral Home d, dZA'(ZA
IMPORTANT:
I represent that to the best of my Ivrowledge,the deceased(has)or(has no)peoenhalrer,defibrillator or any other bettery operated
device in his or her body. (Circle One)
I cm*that 1 have full power and authorization to arrange for the cremation of the remains and to dired the dISPOSition of the
cremated remains,that arty personal possessions hove sOm been removed or may be destroyed.and agree to protect,defend and
save themhless Pine View Cren**Wurn from any and all claims and demands for Ices or darnag A 4 which may be made against them
by reason of or connected with the crernetion of sold remains as directed,whether such d*m or demands are or are not wholly
C�fraudulent.
(Witness) (Address)
(Sodwfe and Address of Relative or legal Representative)
Signed on this date: -)21`0
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remeirhs as follows
Mati to /Ll• �'- �L�rz�c���- -
odw arrange"W is-Please specify:
If pulverization of cremated remains is requested,aback here
Revision:January 1,2M
,
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 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 male 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 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 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