Grady, Muriel PT
OF QUEEr\�50UT'yPLN1r V7EW CE CEMETERY AND CREMATORIUM
QUAKER ROAD, QIIHP.NS9URY NEW YORK 12804
(518) 745•4476 (518) 745'•4-477
Funeral Director
�aTe
� arK
�uc x re,e'y
Case #
:ate Of Cremation
: ^e Cremation Started
-------------
' '"e Cremation Completed 9 ' 41� �M
� rPe of Container
C o•l, C� L iSr �
Remarks
A tJ 7 -;0
IN o F Y 30 Atf
� SoAIL-
el
. qcf
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 autitor'raes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate ft remains oL
MURIEL L. GRADY FEMALE
(Name) (Sect)
89 GREENWOOD ST. .LAKE PLACID, NY !@($¢
( ) (City) (state) (zip Code)
who died on 0 3 r d day of MAY 2p 0 7
at AMC at Lake Placid
(Piece) (Address)
Name and address of nearest Vving relative or name of person auAtrorb"cremation:
MICHAEL GRADY 34 LIBERTY HILL LANE LAKE PLACID, NY
(Name) ( )
Relations) to the deceased BROTHER
Name of Funeral Home_ M. B. C L A R K. IN('.
IMPORTANT:
I represent that to the best of my Imowledge,the deceased(has)a tres r pecerrraker,defibrillator or any o0w barmy operated
device in his or her body. (Circle One)
I certify that i have full power and authorization to arrange for the crerrration of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eWw 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 lose or damages wtdch may be made against there
by meson of or connected with the cremation of said remains as dNected,whetirer such claims or demands are or are not wholly
grour diess a or fraudulent
( \ 2310 SARANAr AVF. , LAKF PLACID, NY
( )
LIBERTY HILL LANE, LAKE PLACID, NY
(Signore and Address of R,Odrve or Legal Representative)
Signed on this date: MAY 4, 2007
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mallto M B CLARK, INC.
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Other arrangements-Please speGfy:
If pulverization of cremated remains is requested,check here x x
Revision:January Z,2006
Policies, Rules and Regulations
1. Pine View Crematorium is boated 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 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.
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.Then: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