Collard, Dean Ilu
07
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P'NE YTEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEIVSBURY, NEW Y
(5; 8) 745.4476 ORK 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 unde sired requests and atdiorbw Pine View Crerrolorkrm,in accordance with and subject to its Rules and Regulations to
cremate the ren*ns of:
Dean Collard Male
(Nance) (Sex)
2660 StateRt 28 , North Creek, NY
(Street) (City) (State) (Zip Code)
,Am died on 17th dayof June 2o07
at Glens Falls Hos
(Place) (Address) --
Name and address of nearest riving reiaQive or name of person auttcorizacg cremation:
Hilda _F. Collard, 1822 State Rt. 28N, Minerva, NY
(Name) (Address)
Relationship to the deceased Mother
NameofFunerwHome Alexander FH, Inc, North River, NY
IMPORTANT:
I represent that to the best of cry ivrowledge,the deceased(OW)6r(has no)pacemaker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device In his or her body.(Circle One)
I oe*that 1 have fill power and actttcorization to arrange for the cremedon of the remakbs_and to direct the disposition of the
cremafad remains,do any imsonal possessions lave either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View�iemetorl rc and all claims and demo for loss or damages wtcich may be made against there
by reason of or q
W neW wkh the of said remains as directed,whedw such c lai ns or demands are or are not wholly
or
Warrensburg, NY
(Address)
Same as •above
(Signature and Address of Relative or Legal Representative)
Signed on this date. 6-19-0 7
Disposition of Cremated Remains
I hereby direct Pine View C rematoritan to dispose of the cremated rerneft as follows:
Mail to
other arrangements_Please specify: FH will pick up
If p Awmation of crernated remains 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 7:00am 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 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. Cremadons 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 knuNal tame
handling the service unless other arrant are made.There will be a$30.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
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