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Troisi, Mathilda 2"O OF QUEEN,50ur :�'. PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, Q(j3ENSBURY NEW YORK 12844 (518) 745-4476 (518) 745-4-477 n,� Funeral Director ���� Fame M�k� l� ( ro 5 � C a s e# �2 date Of Cremation ` v US Time Cremation Started T :me Cremation Completed 10 = SO Type of Container Remarks ���= VO( l 35Z 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 7770' ' (Name) / / / (Sex) A/ G �,t /ew b'� " /� (Street) (City) r-� (State) Rip ) who died on day of V �� /20©0 L at (fie) MSS) 7,0- 7/ 7 of nearest living.reiative or name of a creme d ,�"1209 ril,el--/6 2�: (Name) (Address) ���` Relationship to the deceased Name of Funeral Home ! C G IMPORTANT: I represent that to the best of my knowledge,the deceased(has) jhssno�)paoemak defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device in his or her body.( ae I 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,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 toss or damages which may be made against them by reason of or connected with the cremation of said remains as directed,whether.such claims or demands are or are not wholly groundless,false or fraudulent. J rl v r� `i"Uf (Address) 3/ lin ( ignat and Address of Relative or Legal R esen tive) Signed on this date: Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: If pulvertzation of cremated remains is requested,check here Revision: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: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 Pure 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 pack, 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 the 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$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 (stillborn to 12 months) $130.00 Overtime Cremations(Weekdays) $480.00 Saturday Cremations $480 00