Waldron, Jay OF QUEE�0ur
PINE VIEW ,CEMETERY AND CREMATORIUM
gtlAk` ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director
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Date 0( Cremation
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Time Cremation Started �; ►:�`
Time Cremation Completed
Type of Container i2
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury.New York, 12804
Cemetery Offim Sig-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The undem%rled requests and scAwtixes Pine View crenator+ura,in a=nftnm with and subject to its Rules and Regulations to
cremate the rernains or
Jay F. Waldron Male
(Name) (Sex)
2716 St . Rt. 9 , Lake George, NY 12845
(SUIM) (try) (state) (Zip Code)
who died on 2 8 t h day of October zu 8
at 2716 St . Rt . 9 , Lake George, NY 12845
(Place) (Address)
Name and address of nearest living relative or name Of person auMWZUV crerrtattatt:
Holly Waldron 2716 St. Rt. 9 , Lake George
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my Wwwedg%the deceased(me}or(tms no)pacemaker.deffimilatm or any odd battery operated
device in his or her body. (Circle,One)
I certify that I have ttr>tBs. m arrange tDr the c reffoliort of the rem and to direct the dWposftion of the
cremated m ' ,that any l possessions have eMw been removed or may be deslmyed,MW agree to protect.defend mid
save Pine Vi matcxium from any and all daims and dwvards for km or dwriages which may be made against them
by of or vAM ttte crarimgm of said movErrrs as i2mK2mX vNeew such dorm_s or demos ate or are not wholly
g false ftsadt kmiL
(witness) (Mdress)
�I�CAS &A -nature and Address of Rekd a or regal Representative)
5igneaontntsuate: October 2!1, 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as hollows:
Map to
Other arrangements-Please specify: F H w i l l n i c k r i ri
if pulverization of cremated remains Is requested,cheCK We x
Revision:49 ' t
/ r?! 07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the groom at Pine View Cemetery.The
crematorium operates Monday through Friday from TOOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations-
2. A "Authorization for Cremation's.K>ned by the nearest ne)d of kin is necessary stating
that they do have the power and auftafty to arrange for the cremation of the remains
and to direct the disposition of the cremated rwiai€j,that any personal dons
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 there by reason of or connected with
the cremation of said remains and/or disposibon of said remains as directed,whether
such claims are, or are not wholly grourdless,false or fraudulerd.This aut ortm ion in
addition to a regular burial permit must accompany chic 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 wed devices must be removed
before any remains will be accepted,
6. Cremations will be coffgAeted wi n ftee 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. Avail widdn three days of cremation to the funeral home
handling the service unless other arrangements are made_There vA be a$2&100 charge
for this service.
6. Cremation, Administration Costs and Reding Fees.
Adult 1 33o,
Children (age 13 months to 12 years) $ 190-
I nfa nts (stillborn to 12 months) VDG-W' I.3 c e"L