McCane, Ronald OF
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PLNE VIES' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /
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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 accordance with and subject to its Rules and Regulations to
cremate the remains of-
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(Nam) (Sex)
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(Street) (City) (State) (Zip Code)
who died on Z G day of20G
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Name and address of rreerest living relative or name of person authorizing aernsbon:
(Name) (Address)
Relationship to the deceased Si S-;;'►Z
Name of Funeral Home A L CVWO C-? ����.— AIVMt /2( ,Alfpe
IMPORTANT-
I represent that to the best of my browledge,the deceased(has �no) ,defibrillator or any other battery operated
device in his or her body. (Ci de One)
I certify that I have full power and acdh xtimbon to arrange for the cremation of the remains and to dk ed the dspositan of the
crenated rams any possessions have either been removed or may be destroyed,and agree to protect,defend and
pbyEof
roria
View from any and an daims and demands for loss or damages which may be made against them
�=thetion of said remains as directed,whether such daims or demands are or are root wholly
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n Address
(Signahue and Address of Relative or Legal Representable)
Signed on this date: ? -.)
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
tail to
Other arrangements-Please spedfy: ar at)
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
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 nor.Prearrars 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 possessionss
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 aRemate 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 creffm ted 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$30.00 charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $4.50.00