Brown, Martha s.�
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PWE VIEWQUEE9�5OU
J�(y
CEMETERY AND r �.J
QUAKER ROAD CREMATORIUM
QPNSBURY. NEW YORK 12804
(518) 745.4476 (518) 745-4477
Funeral Director
LFame
,,
Case. L)
Dace Of Cremation
Time IC Uv
Cremation Started
Time Cremation
Completed
Type of Container
Remarks
41—ty iU
"`• i :'" Pr`l
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 o..
�i(Nam)
u�sJ
(Street) (City) (State clip Code'J'/L�7
who died �� day of6- 20�
4 /CC44 - s
(AaareSS)
Name and address of nearest living relative or name of person authormng cremation:
.T —L&A lfUcY lam-!
(Name) 774
Relationship to the deceased It (/ / v
-,
Name of Funeral Home G'—z L
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 loss or damages which may be made against them
by reason of or connected with MeGhlation of said remains as directed,whether such claims or demandsare or are
rnot wholly
y
(Signature Address of Relative or Legal Representative)
Signed on this date:
--- Wpoossitioonn�of Cremated Remains
I hereby direct Pine View ematorium to dispose of the cremated remainst3s lows:
Mail to
Other arrangements-Please
If pulverization 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 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
09/12/2008 01:06 15184942948 BARTON MCDERMOTT FHN PAGE 02
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Autjwrization to Cremate
The""slgrW requests and wAttortzw PBte View C wnstoAum,in socor wce wkh end wojea to its Rubs en0 ReguWons to
cremate the renlow of
(Name) (Sax)
/ (��' .� (city) (state (tip codef/ 7
who &V 20
)
Name and address of merest Rvkv teletive or rune d person elrth=kdv nen►etlon:
RekoonsW to the doomseedd -
Name of Funeral Home
IMPORTANT.
I reMmard that to the best of my kvwiedga,the deosasad(has)or(has no)pacemaker,0aarlWor,battery,battery Pea.PAr
csiL radloedw Mnplent or n0opalve devios in We or her body.(Circle One)
I certify that I have full power and wAhmUstlon to emerge for the awnedon of the remains and to direct the d4oWw of the
cremated wnelm.that any personni posseaslons nova aftrw been r moved or may be destroyed,and agree to proteM derend and
save hertnless Pine View Cremetorlurn front any end all delms and demertde for kris or daniv a which may be made ape:tst them
by resson of or connected with t' tattoo d sald remains as directed,whtelher.such csms or dernends we or are not who#y1/3
(S rmtm Address of RebUve or Legal Representable)
Stgnea on this date.� �� 4�� --
poskign of Cremated Remsko
I hereby&rect Pine Vlew metorlum to dispose of�O—Wwted ramatrts�s
Mail to
oa&er errangementa-Ptease
If puNertzation of cremated remskv is requwed,&odc here
Revision-April 18,2007