Thompson, Sarah TOWN OF Q UEENS B U•R Y
Pine View Cemetery nud Crematorium
21 Quaker Road, Queensbury, NY. 12804.5902
(518) 74 5-44 76 (518) 745.4477
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Funeral Director:
Name of Deceased:
Case Number: (,
Date of Cremation:
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Time Cremation Started:
Time Cremation C77L
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Type of Container:
Remarks:
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Home of NnluraI Benuti
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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 undersigned requests and a d*rUss Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains ot:
Sarah F. Thompson Female
(Name) (Sex)
185 Old Military Road, Lake Placid, NY 12946
(fit) (City) (State) (Zip Code)
who died on 2 8 t h day of April 2D0 8
at Uihlein Mercy Ctr. , Lake Placid, NY
(pie) (Address)
Name and address of nearest living relative or narne of person authorizing cnemerim:
Mrs Sarah Adams Box 133 1Vilmington, NY 12997
(Name) (Address)
Relationship to the deceased Daughter
Name ofFunerwHome m B. Clark, Inc. ,--Lake Placid, NY 12946
IMPORTANT: def rMecor.betimy, y peck.Per
I represent that to the best of my Ivwwiedge,the deceased(has)a(has m no)paceaker.
cell,radioactive implant or radioactive device in his or her body.(Cirde One)
I certify that I have full power and audxxization 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 hermim Pine View Crematorium from any and an daims end demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whather such claims or demands are or are not wholly
gnx�r�Iless,f or fraudulent.
2310 Saranac Ave Lake Placid, NY 12946
(Witness) ( )
Box 133 wilaington, NY 12997
(Signature and Address of Relative or Legal Representative)
Signed on this dace: April 28, 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispoVW the cremated remains as toliows:
Mailto M. B. Clark Inc 2310 Saranac- Ave. , Lake Placid, NY 12946
Other arrangements-Pleesa spedfY
if pulverisation of cremated remains is requested,check here xx
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 Bairns 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 alternate container. Caskets and containers
must be of a combustible material. No styrnfoam or plastic containers will be accepted.
4. Any cardiac pacemakem defibrillators, battery, battery peck, per 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 fib home
handling the service unless other arrangements are made.There will be a$30.00 charge
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
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