Mather,E. Mural f
OF QUEE9�50U ,�
LNE YTEW CEMETERY AND CREMATORIUM
QUAKF—R ROAD, QijEENSBURY NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
Name Funeral Director �Ut?t•>;�
�tJr"`f
Case # g3
Date 0 ; Cremati.on
Tame Cremation Started
-
---
Time Cremation Completed
Iv � � h
Type of Container /f '� _
S,Cl7r�IVd {C K —
�emar'Ks !SI C,y56
Mw� g,30
9 . 00A
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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)745-4477
Authorization to Cremate
The undersigned requests and autironfzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
09%aw"remains Of.
(Street) > (fie) (ZJp Code)
who died on zt day of ' 20at
(Plece) ell O
Name and address of nearest IIvMp relative or name of person au#wrb*V cremation:
(Nam) (Address)
Relationship to the deceased ' ,>
Name of Funeral Harris
IMPORTANT:
I represent that to the Kest of my lonowiedge,the deceased(bnOer deffbnillator,battery,battery peck,power
cep,radioactive Implant or radioactive device in his or her body.
1 oe*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 eMw been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Cranvmxium from any and all claims and demands for loss or damages wtdch may be made against them
by reason of or connected with the cremation of said remains as directed,whedw such daims or demands are or are not wholly
grourdlem fain or ftaudulent.
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: try ';2Cd vat
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated m(neMns 99 follows:
Map to
Other arrangements-Please specify:
If Wtverizadon of cremated remains is requested,check here
i
Revision:April 18,2007
Policies, Rules and Regulations
1. Pine View Crematorium is looted 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 paoerrrakers,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 funeral home
handling the service unless other arrangements are made.There wiN be a$30.00 dharge
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