Nelson, Lucille �O O— QU E E
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PCNE `"EW CEMETERY ATYD CREM
QLti}CP� ROAD, Q�ENSBUIZY, M
NEW �T ATORfU
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(518) 745 4476 (S18) 745'.4477
Funeral Director
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Town of Queertsbury
Fine Ytew C lmetery and Crematorium
21 Quaker Road.Queerisbury,New York, 12804
Cemetery Office:(518)745-4476.Crematmiurm(518)745-4477
Auftwb ation to Cremate
The undersigried rem and WAMrims Pine View Q+Eweelorkim.of 8000rdenoe with and subject to fis Rules end Repletion to
cremate the rerntakns of
LucilleNe_lson F maIP
^' (Name) (Sex)
1VW Acv /ZcTr6
(Street) (City) (State) (Zip )
who died on 2 8 t h day of= T t i l y 2Ey—Q.7
Ft. Hudson NH, Ft. Edward, Ny
(Plaw) (Address}
Name and address of nearest k*v relative or name of person ahs:ho b*V cremation:
Andrree)w Nelson son Spy -- 4J /93c
m 3e(Address)
Relationship to the decessed S o n
Narne of Funeral Home A l P x a n d P r F i-i - T n r . N n r t h R i v a r N y
IMPORTANT:
I represent that to the best of my knowledge,the decweed Xr(has no)peacemaker,dellbriiiator,battery,battery peck,power
cell,radioactive implant or radioactive device In We or her body.(Clade Clyne)
I cer*y that I have full tatiort to arrange for to cr A"00011 0f 8te remak1S anal to OW the d silos tion of the
cremated cerrna any pets seaeionrs have elMher been MMFed or may be deWaye4 and agree to protect.defend and
save hens View um ham anti and all daims and demands for knee or damages wlich may be made agiiinst them
by ,toe the cremation of avid wmains as akecled,whet such her su claims or demands are or are not wholly
WarrPnsburg -
(Address)
X Same as above
(SqA#E0Wand Address of Relative or Legal Repveserfttive)
signed on this date: 7-2 8-0 7
lisposioon of Cmffg ed Remains
hereby Bred Pine View Crematorium to dispose of the oemeted remains as folsowe:.
Mail to
Omer anangernenls-Please spedty: F H will pick up
If MMNbzfim of arama[ed remains is requested,chuck hers_X
Revision:April 18,2Cn07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Frkiay from 7:O0am to 3:30pm. Prior telephone
arrangements for the eooeptance of remains are nor.Prearrangements are
necessary for overtime or Saturday cremations.
2. A 'Authorization to Cremate form signed by the rarest next of kin Is necessary stating
Met they do have the power and authority to arrange for the cremation of the remains
and to direct the disposition of file cremated rernains,that any personal possessions
have either been removed or may be dyed and agree to protect,defend and save
harmless Pine view Cemetery and Crematorium from any and an dims and demands
for loss of damages which may be made agairo them by mason of or connected with
the cremation of said remains andfor disl�on of said remains as directed,whether
such claims are,or are not whoNy groundless,false or fraudtdenrt.Ties au boon in
addition to a regular burial permit must accompany the remains.
3. AN remains must be in a casket or suitable akernate container. Caskets and cons
must be of a combustible memorial.No ern or plastic eorxa*s wiN be accepted.
4. Any cardiac paoentakers,defil--Mators,battery,battery pack,Power cell, radioactive
d ve devi
implant or race roust be r+ei x*W firom the body before any remains will be
accepted.
5. Cremations wig be compiled within hires working stays(72 hour`s)of receipt of the
Burial Transmit Permit and Auftrb:ation to Creme Form.The cremated remains will
be mailed via Registered U.S. Mal withit tlxee days of cxaerrteOm to the fiwwrd home
handling the service unless other an= g=wIi 11s ame made.Theme w9 be a$30.00 charge
for this service.
6. Cremation,Administration Coifs and Recording Foes.
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