Mott, Steven TOWN OF QUEENSBUR Pine View Centelery and Creutalorinin Y
21 Quaker Road, Queenshury, NY. 12804.5902
(518) 745.4476
http:i/w%v%v.queensbu ry.net (518)745.4477
Funeral Director. 0 r-fa
Name of Deceased;
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Case Number. Z b L
Date of Cremation: J
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Retort: C
Time Cremation Started:
Time Cremation Completed: 3 vv PF
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" Home of Nalural 6enuly ... A Good PInce to Liue "
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 brad requests and NAWtess Pine View Cremaio rn.in accordance with and subject to its Rules and Regulations to
cremV the remains of:
(Name) (SIX)
(meet) (City) (State) (zip Code)
who died of day of 20 O r—
at P , UT
(Ph") ( )
Name and address of nearest Nving rem"or name of person adhortrhrg cremation:
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ReWdonship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my lowwiedge,the deceased(has)or(has no)pacemaker,deiibrilletor,battery,battery Pam.Power
can,radioactive implant or radioactive device In his or her body.(Circle One)
I certify that 1 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 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 agWW them
by meson of connected with the cremation said remains as directed.whether such clelrns or demands are or are not wtwlly
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(Signature and Address of Relative or Legal Re�presentative)
Signed on this date: /ve pr
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remall"Sa follows:
Mail to
Other arrangements-Please specify:
ff puNerb ation of cremated remains is requested,check here k x�
Revision:April 18,2007
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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 alternate container. Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Any cardiac paoernakers,defibrillators,battery,battery Pam, 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 anangernents 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 (stilibom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00