Johnson, Martha O QUEE9\�50UT_7
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PINE VIE
CEMETERY AND
QVAR ROAD CREMATORIUM
(518) 745.4476,4476 BURY NEW YORK 12804
(518) 745'•4477
Name Funeral Director
=a : e Of Cremation Caser �a
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Cremation Started
, ' me Cremation Completed
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Remarks
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CoGL �. S
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)7454476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and audxxv s Page Vrew crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains c
MartharE. Johnson Female
(Name) (SOX)
1240 Sr Rr 28T, Olmsteadyille, NY 12857
(Streel) thy) (State) Mp Code)
who died on 23 day of April 2 0 7
at Glens Falls Hospital , City of Glens Falls
( ) (Address)
Name and address of nearest living relative or name of person author(*v cremation:
Phil F. Johnson Olmstedville, NY
(Name) (Address)
Relatiorwt*to the deceased S o n
Name&FtnerdHome Alexander Funeral Home, Inc.
IMPORTANT:
I represera that to the hest of my lvrowiedge,the deceased(has)or(has no)peoemalw,deftire r or any otfrer bury operated
device in his or her body. (Circle one)
I certify that I have fun power'end authorization to WNW for the crecnalion of the Mmafs and to direct the disposition of the
cremaiedr� that persona( siais have ektw been wxyved or mw be deed,and agree to protect,defend and
saw any and all claims and demands for toss or damages which may be made agamst them
byewith aerrratbn of said rernams as drected,whether mch dmm or demartb are or are not whW
false
Warren sbur
(Address)
Olmstedville
Address of Relative or Legal Reprr alive)
Signet(on this date: April 23, 2007
Disposition of Cremated Remains
I hereby difW Pine View Crematommn to dispose of the cremated remains as follows:
Man to
other-Please specify: Rtn to Alexander Funeral home
If Pulverization of cremated remains is requested,check here X X
Revision:January 1,on
'r r
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
Creff0orium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary.Preenangements are
necessary for Saturday crernations.
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 cxernated 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 motion of said remains as directed,whetter
such damns are,or are not wholly groundless,false Or fraluiulent 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 waking days(72 hours)of receipt of the
Burial Transmit Permit and Authaization 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