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Detore, James ki -t rM OF QUEEr7\�S(BuPWE VIEW CEMETERY A Till' QUAKER ROAD CREMATORIUM QUF:1:'NSSU}ZY�(518) 745.4476 NEW YORK 12804 (518) 745•4.477 Funeral Director NameJc,�.S �t p Cased. �( Date Of Cremation VOq Time Cremation Started q 2; Time Cremation Completed Type of Container Remarks' M ►� t:3 C"`' I t Uc7 —__ Ciz 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 the remains a (Nam) s>~�� 33713 (Street) (City) (state) (Zip Code) who died on A day of .�-e o71 h-S£t 20Q t� at A A�Sc S (Ph") ( ) ( ) Name and address of nearest living relative or name of person authorizing cremation: 04C,�&.c,-o-5 Q 47-&9 Jc ( ) (Address) Relationship to the deceased 3oA.) Name of Funeral Home �4DI�a ✓7' IMPORTANT: I represent that to the best of my bwwledge,the deceased(has)or(has no)pacemaker,delibrillator,battery,battery Pam,Power cell,radioactive implant or radioactive device in his or her body.(Circle One) 1 oertity that 1 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,deWdd and save harmless Pine View Crematorium from any and eii derma and demands for Joss 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 grourx 7 Hess, a � y � (Address) b Rd an AeA's /C�,o ©Pay (Signature and Address of Relative or Legal Representative) Signed on this date: /o ,f a Disposition of Cremated Remains I hereby dyed Pine View Crematorium to dispose of the cremated remains as Maws: Mail to Other arrangements-Please specify: If putverrzawn 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 -AudlOrbmtion 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 haimiess Pine Vewv Cemetery and Crematorium from any and all claims and demands for loss of damages which may be made against them-by r t-ofor mnneded with the cremation of said remains and/or disposition of said remains as&ecl'ed,whether such claims are,or are not wholly groundless,false or frauduent.This acrt wbation 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 conlaners must be of a combustible material. No styrofoam or plastic coritamere Will be accepted. 4- Any cardiac pacemakers,defibrillators, battery,battery Imo, power cell,radioactive implant or radioactive device must be removed from the body before any retrains will be accepted. 5. Crermations will be completed within three working days(72 hours)of receipt of the Burial Transmit Permit and Authorization to Cremate Form.The cremated remains wail be mailed via Registered U.S. mail within three stays of cremation to the funeral home handling the service unless other arrangements are made.There wig be a$30.00 doW 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