Sendzik, Richard l_
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PWE VI QUEE9�5(BUTT
EW CEMETERY A�
' QUAKER ROAD, CREMATORIUM
QUEENS13URY. 1`BW YORK 12804
(518) 745.4476 (518) 745.4.477
Funeral Director
Name� 17
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Time Cremation Z Lb�
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T ' me Cremation
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbf ry,New York, 12804
Cemetery Office:518-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The undersigned requests and audiort o s Pima View Creavdamun.in a000rdanoe with and sited to its Rules and Regtdmions to
cremate the remains of:
_Richard Sendzik Male
(Name) (Sex)
83 Konci Terrace Lake George, NY 12845
(SUM) (CRY) (Sate) (Ztp Code)
whodwon September dayof 17 2c 8
Adirondack Tri-County Nursing Home
(Place) {Addre�}
Name and address of nearest living relative or name of person auvwrtw g cremation:
Kim Sendzik(son) 83 Konci Terrace Lake George, NY
(Name) ( )
Relationship to the deceased S 0 N
Name ofrwnerWiionvAlexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my know�,the deceased(has)c r(has no)pacer.deftdIIetor or any outer battr#y operated
deVme In his or her body- (Cirde One)
I certify that I have full power and art atzabon to arrange for the aernalm of fhe oemins and to direct the d4osition of the
cremated remaEcEmectEe (
possessions have either beers removed or may be destroyed,and agree to protect,defend and
save hamoriwm from any and ad daims and demands for loss or which be made them
by orthe cremation of saki remains as directed.whelher such daims or demands are or am not whotiy
g false or
(Address)
(Sigrtattue of ' or Legal Representative)
Signed on trus pate: 9/18/0 8
\\j
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
marito Funeral Home will pick up.
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,dxx*here X—
Revision:Jyiy 7�0�1
/8liA",07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grog 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$2&.,00 charge
for this service. .`-�-
6. Cremation, Administration Costs and Recording Fees:
Adult $39&i - ` 33O'�
�-Children (age 13 months to 12 years) $3 t go- LP
Infants (stillbom to 12 months) - 13C--
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