Keyes, Christopher 07 QUEE9\�50UT
PLNE VIES' CEMETERY AND CREMATORIUM
QU&KER ROAD, QUEE.NSBURY, NEW YORK 17BO4
(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: > G, X
(Name) 41 Sex)
v�7,- e s'��� 1. ate) (zp c«le)
(Street) > (City)
who died on / 7 e day of 2D&7
at 1C iu inri ZiGCr 0 .cz � vT
(piece) (Address)
Name and address of nearest living relative or narne/9 of person�autbort=V
Relationship to the dew
Name of Funeral Home
IMPORTANT: ,defibrillator,battery,battery Pack,power
lv
I represent that to the hest of my rowledge,the deceased(1+ad< ra)
cell,redfoective implant or radioactive device in his or her body.(Cmcle
I certlfy that I have full power and authorization to arrange for the cremation of the remains and to direct
�d to�K��of the
end and
l have either been removed or may be destroyed,
save hhaarrml View wG�from any and all claims and demands for loss or damages which may be made against them
by meson of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
77;;�L�
ndls false or fraudulent.
C. b 1 1 1'� V' �°1. N
(Address)
(Signal Address of ReYatN Legal Representative)
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Signed on is date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to //ff
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other arrangements-Please specify:
If pulverization of cremated remains is requested,cha&here
Revision:April 18,2007
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 overtime or Saturday cremations.
2. A `Authorization to Cremate'form 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 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.
I 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. Any cardiac pacemakers,defibrillators,battery, battery pack, power cell, radioactive
implant or radioactive device must be removed from the body 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 dhys of cremation to the funeral home
handling the service unless other arrangements are made.There will be a$30.00 cage
for this service.
6. Cremation, Administration Costs and Recording bees:
Adult $330.00
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00