Lawson, John Jr. OF QUEE9�5�BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4.477
Funeral Director
Name J6�� Z4w6ok j7r,
C a s e#
Dace Of Cremation I— (7-01
Time Cremation Started
Time Cremation Completed
Type of Container �,,rAo6,
5F
Remarks
i �U:�6
Ctloi lZ %kO
I
01/17/2008 09:46 5184991050 JILLSON FUNERAL HOME PAGE 03
r
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Offlce: (518)745-4476, Crematorium: (518) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pkte View Cramekxium,In Wcordance with and subject to its Rules and RegulAt"to
cremate the ry�e of:
(Name) (Sex)
eftm o ctta
(Street) (any) (s te) (zip Code)
who died on _ /S day of c2AAM • 20 !�8"
1Q� l C ,T
(Place e� . v;llc
(Address)
A1.�• 12 3 Z
Name and address of nearest living relative or name ofperson authorizing awnatlon:
I ,#v—e wH1'Tih1,,�*// Al 847
(Name) (Address]
RelabonshIp to the deceased- ;i'ne(
Name of Funeral Home N.the y
IMPORTANT:
I represent that to the best of my knowledge,the deceased(Ras)or(has no)Wamaker,defibrillator,battery,battery pack,power j cell,radloective Implant or radloa ve device In his or her body.
ody (Circle One)
I cExvty that I have full power and authorization to arrange for the Crerrtatlort of the remains and to direst the dts
cremated remains,that any personal posSe="4 have either been removed or May be destroyed,and o prof n of the
save harmless Pine View Crematorium from any and all claims and demands for lose or damagesy agree to protect.against thorn horn
by reason of of cmnadcd With the c WMILIM of said remains es directed,whether•such clsl demands are or rerK wf"
yrourdles3,false or fraudulent. rr
(Addrt�)
ignature,and Address of Relatl Heal Representative)
Signed on this date:
DispostUon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdlows:
Mail to_
Other arrangements-Please speCffy: W LL RZk
If pulyt-,ruction of cremated remains is requested,Checkthere�
Revision:April 18,2007
I
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 re s of:
� /main O 4'// -7 7 cc,S ri1, I- A—1 4-1-15-
(Name) �^ (Sex)
(Street) (City) (St te) (Zip Code)
wno died on day of S .201191
at ;f 09chattd AlaA*o76 C�nTe nr rv,lle n1 I a83Z
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
.4vze "el'1, 5, /V aldb am 5 5Tefe , w141 7-rlfiy// All. 8Sr7
(Name) (Address))
Relationship to the deceased /`
Name of Funeral Home 7 #50 y
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 all 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 fraudulent.
(W ) (Address)
Qnature and Address of Relativ egal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: ' L� ' 'Z k' !�
If pulverization of cremated remains is requested,check here
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 altemate 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
handling the service unless other arrangements days of cremation to ft funeral home
for this service. n9emerts are made. There will be a $30.00 urge
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