DeCota, Elsie OF QUEE9�,50Ur.�y
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745'-4477
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Date Of Cremation
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Time Cremation Started
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Time Cremation Completed ;ot)
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Remarks
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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 undersigned requests and authorizes Pine View Crematorium.in accordaroe with and wAyx:t to its Rules and Regulations to
cremate the remains of:
Elsie DeCota Female
(Name)
796 River Rd. Thurman, NY
(Street) (may) (State) (Zip Code)
who died on 28th dayof June 2008
at Fort Hudson Nursing and Rehab Center- Ft. Edward
({lace) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mark Kenyon 410 Selfridge Rd. , Ganesvoort
(Nam) (Address)
Relationship to the deceased s o n
NameofFurimlHome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has rho)pacemaker,defbrfN W or any other battery operated
device in his or her body. (Circe One)
I certify that I have full power arimtion to arrange for the aerrtabon of the remains and to direct the disposition of the
cremated remain ny powessions have either beery mmwied or may be deMayed,and agree to protect,defend and
save harm ine View C atonum from any and all claims and demands for b w or damages which may be made against them
by of or the cremation of said remains as directed,whether such claims or demands are or are riot wholly
g less,false or
rtness} (Addrem)
lure of Relative or Legal Representative)
signea on this date: June 28 , 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as to00ws:
Marl t0
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here X
Revision:40(--'
/8I�Asl 07
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 Saturday cremations.
2. A °Authorization for Cremation'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. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
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 arrangements are made_There will be a.$26r00 charge
for this service.
6. Cremation, Administration Costs and Reoordirxt Fees:
Adult $3Ae o6' ;3v.
Children (age 13 months to 12 years) $15G.W 12;0-
Infants (stillborn to 12 months)
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