Stark, Jane 00 � � OF
PLNE DER' CEMETERY AND CREMATORIUM
QUrLKZR ROAD, QUEENSBURY, NEW YORK 17804
(518) 745.4476 (518) 745'.4477
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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 wWarsigrW requests and su Mbxs Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
JaneiStark Female
(Name) (E"" )
2783 State Rt. 28 , North Creek, NY 12853
(Street) (City) (State) (Zip Code)
„ft died ar 21st d9yof June 20 07
at Her home
(Piece) (Address)
Name and address of nearest Wing relative or name of person authoring cremation:
Marion Mnnrop Game as above
(Name) (Address)
Relationship to the deceased daughter
NameofFureraiifome Alexander FH, Inc, North River, NY
IMPORTANT:
i represent that to the best of my lammledge,the deceased (has no)pacemaker,defibr8lator,battery,battery peck,power
cell,radioactive implant or radioactive device In his or her One)
I MVy that I have full power and authorization to anarrpe for the cremation of the remains and to direct the disposition of the
cremated remains,80 anyEE
e sions have either been removed or may be destroyed,and agree to protect,defend and
save tuamless q from arty and all c elms and demands for loss or damages which may be made against them
by reason cremation of said remains as directed,whether such claims or demands are or are not wholly
false a
Warrensburg, NY
1Z (Witness) (Address)
same as above
(Signature and Address of Relative or legal Representative)
Signed on this date: 6-2 2-0 7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the crerated remains as follows:
Mall to
Other arrangements_Please r_ FH will pick up
If pulverization of cremated remains is requsested,check tee 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:OOem 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.
3. All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material.No styrotbam 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 days of cremation to the fixWal home
handling the service unless other arrangements are made.There wib be a$30.00 cfiarge
for this service.
6. Cremation,Administration Costs and Recording pees:
Adult $330.00
Children (age 13 months to 12 years) $180.00
Infants (stiilbom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00