Moon, Robert e
OF QUEEN
SB ` 2 r
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 128D4
(518) 745-4476 (518) 745'-4477
Funeral Director A(eti-�er
C a s e# (V "16
Date Of Cremation
Time Cremation Started
tv PM
Tame Cremation Completed------------
Type of Container �n10V� Z 64S
Cie w �e,P Remarks
-----------
COOL
r-
l6
umatOueensbtwv
21 Qttdm Road.C hoolnstxey.New Yak 12804
'emewy OMm(518)745.4M.Cman lAw-(518)745-4477
Autltott to Cremate
The urtdersigtted tequ08fs �1df tOflilBt3 PM Vkftr C�e0pi1t1[st,b taocOrdmoe vrlRh and to its Rules arxi Regulations to
a maw the rertte4R =x
Robert Moon Male
(Nam) (sm)
6 Quoddy Blvd. Lake George NY 12845
(street) (City) (SWO) (zip Code)
„AvdWo, 24th dyof February " 08
at 6 Quoddy -Blvd'r- Lake George, NY 12845 '
(Place) (Ad*m)
Name and address of nam d My abet*or name of person a awkirg cremation:
Katherine Moon 6 Quoddy Blvd. Z f&,,E moo, µ,(,
(Name) (Address)
ReiationaNp to the deceased .W i f e
Nan*ofFunerafHorra '-Alexcander-Baker Funeral Home
IMPORTANT:
I mpmew t that to pta.bo oti y.ptwr(efim ttm domeasd Q"or Om a*peoem kw.deflb Netor,bomy,battery psi.paver
Cell,radios owe krtp wt br•fsdiodctitle dwtoe In his or her body(Cb de One)
I ce*that 1 hava UA paMetr to wmnps3 tOr the ar3c odw of the rttittains and to dsect the dmpa*ion of the
amillow mmakm et:9psal,p. e5btt4 have sober been llpr aved or may be destroyed,and some to protect,defend and
save ttenriese etif if im 4wp srry and a®debo mid Id t---'-bres b or demepes Mdich may be msde a them
by mewccrwtedXsd' a�sttterfon d said renmine ae vireims eudt dekns or demands are or are r>at whoiiy
telasgr. .
(W )
(.S'ipnaturs and Address of Reb im or Leo Reprww t *e)
SW*dontftdmw February 26 , 2008
I
I
ulsposition of Cremated Remains
I hereby dnxi Pk*View Cmnramrium to dispose of the c mmemd remains as follows:
Mail to
I
Funeral Home will pick up
if pu h"rb*bn of c nwnsWd remains is requested,cheCk here x
Revision:Apsfl 18,2007
I
I
Policies, Rules and Regulations
1. Pine View Crematorium is looted on the,pnunds of Pine View Cemetery. The
M"� y �t�M 7:00wn to 3:30pm. Prior teiephone
nary for overtime gemerits for the accepW"of� Y-Prearrangements are
2. A `Audi nation to Cremate-form signed by the nearest next of kin is necessary stating
that#ft do have the Power and ey to arrange for the cremation of the remains
and to direct the disposition of the cr+enmVid rams, that any personal possessions
have either been removed or may be desMYM and egree to Prtect,defend and save
harmless Pine View Cerretey and Crematorium from any and an claims and demands
for toss of damages M*;h may be made againa
are.or are -
the cremation Of said MOM>�/a therm by On of or oonnec�ed with
such claims not dot of said as directed,whether
addition to a wholy '�e or*aUdulent.'tom author t mtion in
regular burial permit must acoompany the remains.
3. All remains must be in a casicet or suitebie akwrw a corftkw. Caskets and oafs
must be of a combs *nil.NO sty OOM Or'Pkmdc cotes wip be aooept+ed.
4. Any car(g=P aloars,d0kidttalam battery.bury Pwk power cell, radioactive
imPkO or radioec"device must be ntrnoswd +orrt the body befOre any remains will be
accepWd.
5. BCMnWkMs will be aanpieW within t"Wv dit days(72 ems)of receipt of the
��l�d��t>Ao C�'It�e Forbf.'Ttt�e arsrruted remair�wiU
be maDed via Ajoijetf U.S MjoWNflil l#t"days Of Ownstim to OW fiirterei home
oceservioe euNess df�er enrargenre�s are ram,There wN be a$30.00 charge
6. Cremation,Administration Costs and $ Fees:Adult
uhibren (ape 13 months to 12 yam) $180 00
IMAM (sWbm to 12 morphs) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations ,► M.00