LaPorte, Connie TO O— Qu T rz
PONE ""EW CEMETERY AKD CREMATORIUM
QU'tiK.eR ROAD, QUEENSBt.IRY,
(S18) 745.4476 NEW YORK 12804
(518) 745.4.477
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 rmdersigned requests and autlmrbw Pine View Crenntoriom,in accordance with and subject to fts Rules and Regulations to
cremate the r+ernains of
C:nnni P T aPnrtP Female
(Name) (Sex)
3772 Main Street, Warrensburg, NY 12885 _
(fit) (CRY) (State) (Zip Code)
vftdWo, 25th dayof June 20 07
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person aunwrizing cremation:
s„— ---- q scr-rRwy fur&-/q
(Name) (Ad")
Relationship to the deceased
Nameowuneraitiome_ Alexander-Baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my Ivrowledge,the deceased MKiX(has nd)pacemaker,deAbdllstor,battery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.(Circle One)
1 certtly that I have full power horization to arrarge for the cremation of the rernahs and to direct the disposition of the
cremated remins a possessions have either been removed or may be destroyed,and agree to protect,defend and
save harm ne view atorium from any and aN ctairns and demands for loss or damages which may be made against them
by of or with the cremation of said remains as directed,whether such cleans or dernands are or are not wholly
a fraudulent,
Warrensburg, NY
(Witte) (Address)
ame as above
(Signature of Relative or Legal Representative)
Signed on this date: 6-2 6-0 7
Disposition of D emated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mau to
Other arrangements-Plea9e spedlY-— pH will n i v k 11 n
If pulverization of crernated remakes is requested,check here X
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 prated,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 stymfoam or plastic containers will be accepted.
4. Any cardiac pacemakers,defibrillators. battery, battery pack, power cell, radioactive
implant or radioadive 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 days of cxernation to the fixwrW home
handling the service unless other arrangements are made.There wig be a$30.00 charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult 5330.00
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