Stewart, Patricia 1'
Qu(E rEB 21
PUCE nEW CEMETERY "'ND CREMATORIUM
QU�Xp� RO �.D, Q( EETiS5VRY, W YORK 12804
(S18) 745.4476 (518) 745.4477
Funeral Director
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Town of Queensbury
Pine View Celery and Crematorium
21 Quaker Road,awry,New York, 12804
Cemetery Office:(518)745-4475,Grematodm:(518)745-4477
Authorization to Cremate
The urxli�, requests and at"tws Pine View ownwrium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
PAV,CiA A .
5�c >
( ) (may) (fie) (zip Code)
who died on day of Ti.�v 20 a
( ) ( )
Name and address of nearest Wing relative or mane of person a 4wri zing cremation:
R'a-I' , I-1A4 "'Ck- �,c//C�
( ) ( )
Relationship to the deceased un fl9 �A,) ��
Name of Feral Home lF'.CJD+Ad49z r lrl el l`f-0
IMPORTANT:
I represent that to the best of my Ivowledge,the deceased(has) a no , de tOr,beteery,battery pecK power
cell,radioactive imptarrt or radioactive device in his or her body.( )
1 certify that 1 have full power and atdttori SUM to arampe for Nte cremation of the remalm and to direct the disposition of the
cremated remains,that any personal possessions tattle either been runoved or may be destroyed,and agree to PM49 ,defend and
save harmless Pate View Cmmdorkm from arty and all chins and demands for loss or damages which may be made against them
by reeson of or �cmnwnwfton of said nmon iris as directed,vAw*er such claims or derrtartcls are or are not wholly
groundless. or fro
( andor )
Signed on this date: '7, /f
t&spoMon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arangernents-Please specify /C��U 'L'r � tn�� ic/7-
If putverf¢atlon of cremated r errmww is requested,check trees
Revision:Apf1118,2007
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 possesskrss
have either been removed or may be destroyed and agree to protect,defend and save
harmless Pine View Cemetery and Crematoriurn 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 remems as directed,whether
such claims are, or are not wholly groundless,false or fraudulent.Ttft authorization in
addition to a regular burial permit must accompany the remains.
3. AN remains must be in a casket or suitable alternate con Caste and conta
must be of a combustible material.No styr&bam or pWsdc contakWNS will be accepted.
4. Any cardiac pacemakers.ddibr llators, battery,bat my per,per cell, radioactive
implant or radmacxive device must be ner eyed from the body before any remains will be
accepted.
5. Crematiotts will be completed with 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 with ftm days of cne odm to the ftmal home
handling the service unless other arcangwWds are made.There will be a$30.00 charge
for this service.
6. Cremation,Adminft'tion Coss and R�Fees:
Adult
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