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TOWN
i V;e t l OF Q U'EENSB UR Y
c OF
and Crenra►oriuni
21 Quaker Road, Q'Icenshirry, NY. 12804.5902
(518)745.4476 (518)745.4477
hliP://",�vnv.queensbury.net
Funeral Director. -i
Name of Deceased: e
Case Number. Z7
Date of Cremation: Z00`6
Retort:
Time Cremation Started:
Time Cremation Completed: 3%30
TYPe of Container. LI
Remarks:
21�UPq
3�3a Pti
" Howe of Natural Beauty ... A C0011 Plnc•e to Live "
ZA
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Ceretery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
Tne urxiersrgned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
a emate the remains of,
(Narrre) (�X)
(Street) Q (City) (State (Zip Code)
wno died on day of ✓W, 20pg
at
(Place) (Address) _--
Narne and address of nearest living relative or name of person authorizing cremation:
�V
(Name (Address)
Relationship to the deceased / z S-e) I�
Narrb of Funeral Horne— /50
IMPORTANT:
I r(p"esent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and aufhorization 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 fhe cremation of said remains as directed,whether-such claims or demands are or are not wholly,
Orourxiiess,false or fraudulent.
(Signatu an ress of Relative or Legal Representative)
i
this
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
M<r l to
Other arrangements-Please specify: C/L
It pulvc;rizauon of cremated remains is requested,check here
Revrsirx: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 7:00am 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 pacemakers, defibrillators, battery, battery
power cell,
implant or radioactive device must be removed from e body before any ve remains s�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 toe funeral home
handling the service unless other arrangements are made. There will be a MOO 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