Enny, Helen OF QUEE9�5oUl�y
PINE Ew CEMETERY AND
QU' -R ROAD CREMAT
Q�ENSBURY
ORIUM
YORK 12804
(518) 745-4476 (518) 745'-4477
Funeral Director -
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Date Of Cremation _
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Time Cremation Started
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Time Cremation
Completed lU
Type of Container �NJ
Remarks S
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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 remake of:
`tz"---h P r�r3L�
(Name) (SOX)
rifJFS T n'Ia�!!�T /����Tlf y
(Street) ry (City) / (St8te) Rip C e)
who died on o`Jam` day of 57
at
(Piace) (Address)
Names address of nearest Wktg relative or name of audxxt&tg cremation:
(Name) (q ) y
Relationship to the deceased <' h
Name of Funeral Home ti /Son Fatmew �f1rP �c
IMPORTANT:
I represent that to the best of my knowledge.the deceased(has) (has nol3acernaker,defibrillator,battery,battery pack,power
tali,radioactive implant or radbactive device in his or her body. )
certI y that I have full power and audxxttation to arrange for the cremation of the remake and to direct the disposition of the
cremated remake,that any personal possesslorm have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorim from any and all Balms and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such Balms or dements are or are not wttoity
groundless,false or fraudulent.
r
kov Wwre am Address of elatMe or Cegal Representative)
Signed on this date T1.2 16 4
Disposition of Cremated Remake
I hereby direct Pine View Crematodu/m to dissppoee[of the at cremated remake as follows:
Mail to � i��y (iU;` I r'/GG u,r0 /The-3
Other arrangements-Please specify:
tf pulverbuAion of cremated remains Is requested,check here t�
Revision:April 18,2DO7
Policies, Rules and Regulations
1. Pine View Crematorium is looted 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 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 removed from the body 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 $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