LaDue, Rebecca OF
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENS9VRY NEW PORK 12804
(518) 745.4476 (518) 745.-4477
Funeral Director
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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 autliorixes Pine View Crematorium,in aworderwe with and subJW to its Rules and Regulations to
cremate the remains of
REBECCAME_RR�ILL—LaD[JE FEMALE
(Name) (SM)
13 EMMA STREET TUPPER LAKE. NY
( ) (City) (fie) (Zip Code)
who cried on 30th day of APRIL 20)&
at ADRK MEDICAL CENTER C SARANAC LAKE
(Plem) (Address)
Name and address of nearest living relative or name of person mood"awation:
-�T-FPNamHeANIF WHITELAW 217 S�TA7ION RT- ., LAKE PLACID, NY 12946
Relationship to the deceased SISTER
Names of FurrtxAl Fforne Me B. CLARK, INC.
IMPORTANT:
I represent that to the best of my Imo wledge.the deceased(has)or(has no)pamnalter,claNxillox or any other battery operated
device In his or her body. (Cinde One)
i cw*that I have full power and acdhorh ation to arrange for the creration of the rerrrans 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 Crematorlurn from any and all dakrns And demands for lass or darnages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such clebris or demands are or are not wholly
.
771787���
2310 SARANAC AVE. , LAKE PLACID, NY 12946
( ) ( )
�jv r 237 STATION ST. , LAKE PLACID, NY 12946
(Stnature and Address of Relative or Legal Representative)
Signed on this date: .61
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Marto M. B. CLARK, INC.
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Other wrangamenIs-Please spa*:
If pulverization of aemated remains is requested,check here x x
Revision:January 1,2006
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 3:3
arrangements f�'the Opm. Prior telephone
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 per 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
Burial Transmit Permit and Authorization to Cremate Form. The min of the
be mailed via Registered U. S. Mail within three daysated remains will
ineral home
handling the service unless other arrangements are ade There will be as$30.00OO 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) $4.50 00
Saturday Cremations $450.00