West, Suzie TO rRN OF QUEEN,5(13ur
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 128C4
(518) 745-4476 (518) 745-4 77
Funeral Director -
game
Case#
,Date Of Cremation
Time Cremation Started b '
Time Cremation Completed
Type of Container
Remarks
# 335
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 auttionaes Pine View Crematorium.in ecoordarim with and subject to Its Rules and Reguistions to
cremate the remains ct
(Name) (Sex)
(Street) ( Y) (state) (Zip Code)
who died on l q day of , 20 '
at ��r C S -s I63110PI A
(place) ( )
Name and address of nearest K*V relative ar name of person authorizing cremation:
(?-1"L6z Z� (S"c ts-),v -Y iz sr
(Name) (Address)
Relationship to the demsed 04D 6 e>7L s
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or(has no)pacemaker,defibrtilaW or any other battery operated
device in his or her body_ (Circle One)
1 certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains, hove either been removed or may be destroyed,and agree to protect,defend and
save harmless 'r Vlaw Cram m from any and al dalms and demands for loss or damoges which may be made a8airtst them
by or connected the cremation of said remains as&acted.whether such daims or demands are or are not wholly
g false or
(Witness) ( )
(Signature and of Relative or legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematodurn to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
Aaa/' Clio
if pulverization of cremated remains is requested,check here 4—
Revision:J 4
/ � 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,$21r.Q0 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult
Children (age 13 months to 12 years) 12;0-
Infants (stillborn to 12 months) g-80r' 43V