Kelly, Mildred r
'7-OMN OF QUEErA�5BUT,_
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4-476 (518) 745-4477
I� ( Q i( Funeral Director
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Time Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518)7454477
Authorization to Cremate
The undersigned requests and autitortzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
MILDRED P. KELLY FEMALE
( ) (SM)
5924 CASCADE ROAD, LAKE PLA 'TD, NY 12946
( ) (City) (fie) (Zip Code)
who clod on 2 2 n d day of N O V R M B .R 2D=
at RESIDENCE
(Plade) (address)
Name and address of nearest Nft relative or name of person aWhorizirV cremation:
WILLIAM J. K L Y 5924 CASC'ADF. RD , TAKE PT AMD, NY
(Name) (Address)
Re�tiorrship to the deceased HUSBAND
Nemeof Funeral H—mw- M. B. CLARK, TN('.LAKE PLACIn, NY
IMPORTANT:
I represent 90 to the best of my Imowledge,the deceased(has)or(Eq pacemaker,defibrillator or any other battery operated
device In tds or her body. (Circle one)
I certify got I have full power and auftwizatipn to arrange for the aernation of the remains and to direct the disposition of the
aerroted remains,Chet any personal possessions have eitirer been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crerrmtorlum from any and all claims and demerrds for loss or darrragas wtdch may be made against them
by reason of or connected with the cremation of saki remains as tilrected.whetlW such claims or demands are or are riot wholly
gro ,false or fraudulent.
� 2310 SARANAC' AVE' , LAKE PLACID, NY
9 ( ) ( )
LAKE PLACID, NY
or Legal Representative)
Signed on this date: NOV. 22 , 2007
Disposition of Cremated Remains
I hereby direct Pole View Cremstorium to dispose of the cremated remains as follows:
Mailto M. B. CLARK, INC.
2310 SARANAC AVPNr1F., LAKE PT,ArTDF NY 12A46
Other amaripments-Please specify:
If pulverization of cremated remains Is requested,dwick here X X
Revision:January 1,2006
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 Saturday cremations.
2. A "Authorization for Cremation"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. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
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 funeral home
handling the service unless other arrangements are made.There will be a$30.00 charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00