Frances, Reverend Peter TOWN OF QUE' ENSBU'RY
Pine Vietv Cemetery n,ld Crentnloriunt
27 Quaker Road, Queensbilry, NY. 72804-5902
(518) 745.447(
htrP//wN \v.queensbu ry.net (518) 745-4477
Funeral Director: Cl q
Name of Deceased: 9
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Case Number: ( �
Date of Cremation: L(- Z 9, _09
Retort:
Time Cremation Started:
lime Cremation Completed: lt> ;2 U Ah
Type of Container: �Io�L
Remarks:
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" Home o/ Nat itrnI Bennty ... A Good Place to Lite -
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
f'15 P t7fi Al C jS Male
(Nose) (Sex)
45 Es:sex Street, Lake Placid, NY 12946
(Street) (City) (State) ( Zip Code)
who died on 17th day of April 2008
at 45 Essex Street Lake Placid, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mrs. Phyllis Francis 45 Essex St. , Lake Placid, NY
(Name) (Address)
Relationship to the deceased wife,
Name of Funeral Home M.N. OWL Nr-
aranao Ave.
IMPORTANT: 7-Rko Placid, NY 12946
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the 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.
2310 Saranac Ave. , Lake Placid, NY
(Witness) (Address)
`L 45 Essex Street, Lake Placid, NY 12946
(Sig ature of Relative or Legal Rep. and Address)
Signed on this date : 6 0
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows : Thwk.But.
Mail to 2310 Baranao Ave.
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here ✓
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7 : 00
A.M. - 3 : 30 P .M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
2 . Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3 . An authorization for cremation properly signed by the nearest
next of kin or other authorized person 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
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 or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
accepted.
6. Unless other arrangements are made the cremated remains will be
mailed via Registered U.S. Mail within three days of cremation to
the funeral home handling the service. There will be a $20 .00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 .00
Children (age 13 months to 12 years ) $115 . 00 Infants ( stillborn to
12 months) $75 .00
* Additional $50 . 00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .