Boyle, Francis OF QUEE9\�523Ur
PLN
E VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QVEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director
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Case# 3�
Date Of Cremation
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Time Cremation Started
Tame Cremation Completed 10,C7 A
Type of Container '14
Remar'KS
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Town of Quewwbury
Pine Vfaw CF,metiery arty'Crematoriwn
21 QuaW i,Queensbury,New York, 12804
Cemetiery Offir*:ME-) 745-4476,Crematorium:(518)745-4477
Auitwrizadon m Cremate
The undersigned requests and aut hortaes Pine View CmmatorlumI in accordance with and subject to Its Rules and Regulations to
crerrrate the remains of:
(Norns) (Sao
Fouler Ails•.- X,
(Street) (may) —( ta� (7Jp Code)
Who died on U s ` day of_ i f-t/1-I I 20_a_,&—
at Civ„ i!e /tom v s iAAS yA /A71s !► ti►1
Nee and address of relative or trams of person a ewrbft cxentatiort:
d ��?� lT-�-�►�"�a Q a•c.. 7�G �/.'z 1 `u,1�7�r f �? J a 93 Z
cam) cAddress) �'
Relatlorhstrp to the deceased Q,f c "" OCI
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or ,d pr.may, y p�power
oar,redloadit trrrplarrt or redioadlve device In his or her body.
I Cw*Chet I have fur power and authorization to arrange for the aematlon of the remains and to direct the disposition of the
cremated remains.that any pereonal possessions have either been removed or may be destroyed,and apnea to protect,defend and
were harmless Pine View Crematorium from any and all dub=and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said as directed,whether such claims or dernwxis are or are not wholly
orkaudularc
i Zmw—)
' (Address)
(Signature and•.Address of Relative or Legal Representative)
Signed an this date: l/Ond
Disposition of Cremated Remains
I hereby dred Pine View Crematorkso to dispose of the cremated remains as follows:
Mar to —
Other arrargKneras-Please spedfy:
If ptrlverbretion of cremated remains Is requested.check hem
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Revision:Apt 18,2007 ,
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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 aooeptance.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 pack,power cell, radioactive
Implant or radioactive device must be reproved from the body before any remains will be
accepted. -
5. Crem rations 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 m a]ed via Registered U.S. Mail within three days of cremation to the funeral home
hand,!;:,g the service unless other arrangements are made.There will be a$30.00 charge
for th i s service.
6. Crem�,ion,Administration Costs and Recording Fees:
Adult $330.00.
Chiic'Iron (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overt:.;eCremations(Weekdays) $480.00
Saturday Cremations .$480.00