Duers, Craig OFQUEE9�5BUP
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /Q1�exti�c�it
Name ra 0,
Case#, _ RZ
Date Of Cremati.on St 11 ZUG�
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Time Cremation Started 7s3o
Time Cremation Completed 10: e0/l
Type of Container Car ar� Crgw
Remarks
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TMn of QueenSbury
Pine Maw Cemetery and Crematorium
21 Quaker Road, Queensbury.New York, 12804
Cemetery Office:(518)745-4475.Crematorium:(518)745-4477
Authorization to Cremate
The undersigned tames and au0ottes P6te View fit,in as m rig i r P with and subject to its Rules and Regulations to
cremate the remains of:
OZA1 0 2 - 1706"2S /KitL-
(►`lame) (SOX)
(Street) (City) (see) (Zip Code)
who died on l v day of 20
at- --6 L6V r Oku-d lbSpe' SAC
O (Address)
Name and address of nearest truing relative or name of person auritorizhV cremation:
G4ea, Oyce3 Srg6 Al Alauc,
O (Address)
Reiatlonship to the deomsed Lo1 r A6
Name of Funeral Home 4tC-1�0&t. — /34flL;�t �•�,`�2� �/
IMPORTANT:
I represent that to the hest of rtty Ivrowledge.the deceased(he*wfhas no)pacerrreker,deAbritlator,battery,battery pack,power
cell,radioactive impirstt or radioactive device In his or her body.(C.bde One)
I certify that I have AM power and autharization to arrange for the cremation of dte retttaits and to direct the disposition of the
cremated remains,that any personal posoasstonts how eNher bean nsnrtoved or Wray be desMcyad,and agree to prolem defend and
save harmless Pate h m any and al rddms and dareands for loss or damagag which be made
by reason , or With Withtf ernation of said temak as dhecled,whetlrer such claim or demands are or are riot wholly
UdseI
(+ ) (A+ )
,Ck A--I-)( L 11044
(Signature and Address or )
Signed on this date: 7 —.- )—y 7
U"osaion of Cremated Remains
I hereby direct Pine View C renvoorium to dispose of the cremated remains as follows:
Mall to
order arrangernerrls-Please specify. UP
if pulverization of cremated remains is requested,check here
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Revision:April 18,2007
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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 farm 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 d 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 aitemate coritakw. Caskets and oorminers
must be of a combustible material.to stooloarn or plastic cods will be accepted.
4. Any cardiac pacemakers,defsbrilhKors,battery,battery per,pr cell, radioactive
implant or radioactive device must be removed from the body before any remains will be
accepted.
5. Cremations will be amVieted within three working days(72 hots)of receipt of the
Burial Transmit Permit and Authorizaam to Crr'rrtate Form.The cremated remains will
be mailed via Registered U.S. Mail within three bays of crema*m to the Axieg home
handling the service unless odw wm ngernerris are made There will be a$30.00 charge
for this service.
6. Crema*m,Administration Costs and Record ft Fees:
Adult $330.00
t::hildren (age 13 months to 12 years) $180.00
Infants (stilWom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00