Clark, James TOWN OF QU"EENSBURY
Pine View Cemetery and Crenrntorium
27 Qtrnker Rond, Qrreen5bury, NY. 7 2804-5 902
(518) 745-4476 (S18) 745.4477
h(tP iIw%v\v.queensbury,net
Funeral Director: 44
h
Name of Deceased: T
Case Number: �()3
Date of Cremation: 5 i
Retort: o�r
Time Cremation Started: '
Time Cremation Completed:
Type of Container:
Remarks:
1\4 Atv
� v M
. 3
" Home of Natirrn1 8ennly ,., A Gnoif Plncr to Ltue "
# Z03
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745.4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersignred requests and etntrortws Pine View Crerrretorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) ($ax)
f �' i oc.� ��i l X� L}A .�+s A� s ry
(street) . (City) (State) (Zip Code)
who died on a q
_! _ day of kD Q/t.- 20_le
(Ph") ( )
Name and address of nearest living relative or name of person authorizing cremation.
(Name) O
Relationship to the deceased / i'
Name of Funeral Home ��}�L�� C—
IMPORTANT.,
1 reprasent that to the best of my knowledge,the deceased(Tres) no) maker.deftillafor,battery.bettery Peck,power
can,radioactive implant or radioactive device in his or her body.
I certify than I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,no any personal Possessions have either been reproved or may be destroyed,and agree to Protect,defend and
save harmless Pine View Crematorium from any and all cairns and demands for loss or damages which may be made against them
by reason of or connected vAAthe of said remains as dreded,whether such daims or demands are or are not wholly
ground or
47-7
(witness) �z ( )
1o�t Gas is ra
( and Alddrass of ReRativeGo t°Representative)
Signed on this date: C� a d 6 J
Disposition of Cremated Remains
I hereby deact Pine View Crematorium to dispose of the cremaW remains as follows:
Mail to
Other arrangements-Please specify:
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
hamMess Pine View Cemetery and Crematorium from any and all claims and demands
for loss of damages which maybe made against them fiy reason of a�connected with
the cremation of said remains and/or disposition of said remains as directed,whetter
such claims are,or are not wholly groundless,false or fraudulent This authorbmion 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 cc pacemakers,defibrillators,battery,battery per, per cell,radioactive
implant or radioactive device must be removed from the body before any remains will be
accepted.
5. CrernaAiors,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 aeration to the kff*FW home
handling the service unless other arrangernents are made.There will be a$30.00 drarge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $330.00
Children (age 13 months to 12 years) $180.00
Infarcts (stilibom to 12 months) $130.00
Overtime Cremations-ONeekdays) $480.00 -
Saturday Cremations $480.00