Knapp, Olivia QU rE rE
PONE VIEW CE �� �1 �
METERY AKD _
QU CREM,�TORIVM
�R ROAD, QIlEPN38l�Y, KEW YORK 12804
(518) 74S•4�76 (518) 745'•4-477
Funeral Director
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' Jul 19 2007 10: 22AM DURFEE FUNERAL HOME 0022654464 P. 1
319
Town of QueenWmq
Pine View Cemalery and Ommalorium
21 Ckmker Road,Quembury,Now York, 12804
CemsWy Ofrm: (518)745-4476,Crematorium: (518)745-4477 '
Audwdzodm to Cremate
The undersipned requeafs and aulhor'Pas Pkm Vhm Crentetad m.in accordenoe wkh and subject to ks Rules and RequkWoos to
asn�s�e romekts of:
ell
( ) t ) fsmte) (Zip Code>
vAto died on f ' trey of
)
darns and addreea of neerest'NMnp reMetlw or name of paean nrthor"cronm0on:
OL-
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UPORTMtT:
I o op w nt do to the beat of oft,knowWas.the decreeesd Ate«no ps=n roe W.dekbrtlleW belfry.befty cede,Power
cell,nKlaativa krtpbnt or mdW6cit s device In hie or her body,(CUde )
l oerdfy utrt I have kA power mW suWorhad on to arrartpe for the aoatabon'9 0m nmeNts arx+to shred the dbP=Wm of the
aenteted rontllrte,t1tN amr paraond poem wsaio m haw~been ramoved or mey be deavoy+ed,WW epree to Protect.defentl and
sure hermlem Pkn View Cmmatorlum Uvm any and aN debm and del mda for loss or demspmtc which may be me*apakat them
by d tar cor m*sd vrtth the aerrtsdm of veld tentaha as dkeded.whelfw such clekrra or dementia are cram not wiwMy
idea or
• �s�u Sr �,c,�lwJ� �1� l�-e�
( I I end of Ftsietlwe or Legal Repreeantat ve)
Sbrwd on this deter /Af, god 17
Die=Idon of Cremated Aa oft
I ttetaby&act Pm View Cremetonttnt to diapoee of"asmaAsd rarnol"as fbeorrs:
Mall to
mW"Snoemante-Plaaeettpe W.
d pAwriaralbn of demetad nn+Nn.b regttaatw.diedc henv
ReMisbrc�ts,2007
-51
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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
the remains of
(Sex)
(Shim) (City) (State)v (Zip Code)
who died on / �'� day of
(per) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
/t Xiru — &
am (Add �!
Relationship to the deceased _ V',
Name of Funeral Hom
e
`G�� �/ O s ?y3
IMPORTANT:
I represent that to the best of my knowledge,the deceased 0w*4 r 4jjD pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and sutlorization 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 Crematorium from any and all claims and demands for loss or damages which may be made against them
by lapson of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
less,false or fraudulent.
/ /t A-,/
Ur��(
( (Adr)
and of Relative or Legal Representative)
Signed on this date: / OD
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please speclfy:
If pulverization of cremated remains is requested,check here A
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 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. 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.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 (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00