Cohen, Walter OF QUEEN,5BUP
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QOEFNSBURY. NEW YORK 128C4
(518) 745-4476 (518) 745-4477
Funeral Director
Name_ WOtef ah�
Case#
Date Of Cremation S Z� ?
Time Cremation Started I
Time Cremation Completed Z
Type of Container 41A(CIL arJ TF _ C
Remarks
tj 111 -51-10
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
cremate the remairs of:
W (Name)Mi- , ham
�, o -T 1pj 4A� Ec'.h 1--PO o It A 4
(Street)' �1 (City) (State) (Zip Code)
who died on 1 KI oc u� day of SjW-f"6 Gr 2o.�17
at ofr W A7 PO i'A) 1V,y, l?r 9 ti - a•
( ) ( )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the dew I e-
Name of Funeral Home U e 1+m4—
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) no maker,defibrillator.battery,battery pack,power
cell,radioactive implant or radioacive device in his or her body.(C )
I certify that I have full power and authorization 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 ail claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudu t.
G���r (18�3
(W
(Signature and Address of Rela' e or Legal Represen ive)
Signed on this date: 7
Disposition of Cremated Remains
I hereby direct Pine
''P View Cr V 'orium to dispose of the cremated remains as follows:
�
Mail to W C- 11e
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here OA
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 fiuneral home
handling the service unless other arrangements are made.There will be a$30.00 urge
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