Morrison, Nancy E rQU 9�.(5B 71.E
PINE VIER' CEMET>~Ry ^NrD
QUA-KER ROAD, Q�E.NS9URY, M
CR CREM�T AT 1OR(U TU
(518) 745,4476 (518) 745'.4477
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Town of Qu"rebury
Pine View COY and Crematorium
21 Quaker Road,Quewwbury,New York, 12804
Cemetery Offiow.(518)745-4476,Crematorium:(518)745-4477
Authorization b Cremate
The undersigned requesis aatd atfthortms Pim View G1h rknn,m aoeordance wkh and subject to Its Was and Reguations to
cremate the remains of:
(Name) (Sex)
L1 j !�v/�s v�/ s T { (.�/{�2G1/ 4f ul AUj -
(Sheet) (Cky) (State) (Zip Code)
wiho died on z9 day of za c2
at /Vot tibyr e
(PA") ( )
Name and address of nearest living relative or name of person aLdhormng cremation:
OAybN /vW&P4!4 i vt'A2 5� r5l f L4'4X-aJ SM, ,fit' rur�
(name) t (Address)
RelatiorreW to the deoessed l G 60GV
Name of Funeral Home /�C.<✓x',��/� K L✓wU
IMPORTANT:
I represent that to the best of my Wv^%dge,the deceased(has)or(tree no)Pacemaker,deftbrAlator,battery,battery lam.pow
cell,radoactive implant or radioactive device in his or her body.(Code Use)
I cer*that i have M power and a ftdmLlon to arrange for the aernation of to remakis and ID duct do Aspositlon.aft
cxesrrated rerrtah hs,that onai possessions have el im been reshvved or ma r be destroyed.and agree to; f lect,defend and
save harmless Cr a um from any and ao Maims and demands for loss or darrteges which may be made against them
by reeson connected the cram dm of said remains as dlrecled,whether such claims or demands are or are not wholly
false or
( )
( ' Address of Relative or Legal RepreeertatNe)
7b-7 -�
Signed on this date: I/
Lion of Crernated Remains
I hereby dired Pine View CXer�n to dispose of the cremated remains as follows.
Malt to
Other anangernents-Please spedfy: 77-1 L4icL 14L4, LJ
if Prdverustion of cremated rev-mm is requested,check here
Revision:April 18,2007
Policies, Rules and Regulations
1. Pine view Crematorium is located on the grouses of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:O0am 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 atexwky to arrange for the cremation of the remains
and to direct the disposition of the cremated ram,that any personal Pa ors
have either been removed or may be destroyed and agree to protecL did and save
harmless Pine View Cemetery and Crematorium from any and all claims and demands
for loss of damages which may be made against therm by reason of or connedted with
the cremation of said remains and/or disposition of said renwins as directed,whe#W
such claims are,or are not wholly groundlm, or frauduleM Ttft authorization in
addition to a regular burial permit must accompany the rerrairls.
3. All remains must be in a casket or suites altennabe eor . Caskets and containers
must be of a combustible material.No h or Plastic aotAners will be aocepted.
4- Any awd' c pacemakers,ddiibriltcxs,battery,battery pack,power cell, radioactive
implant or rad xx*ve device must be renwNed from the body before any remains will be
accepted.
5- Gnemations wN be com~wid*n ttereree wo*ft days(72 hours)of receipt of the
MEW Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U.S. Man w thtee days of creemom to the fixieral home
handling the service unless other WWQWMwft are Made.There will be a$3000 charge
for this service.
B. Cremation,Administration Costs and R ;e mg Fees:
Adult
Children (age 13 months to 12 years) $180.00
Infants (stillbom to 12 months) $130.00
Overtime Cremations(Weys) $480.00
Shy Cry $480-W