Mahler, Richard Sr. i
1 � ,
OF QUEE9�50ur
PINE VIEW CEMETERY AND CREMATORIUM �y
QUAXER ROAD, QUEENSBURY fix, YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director l
Name ItLt,d Sri, Case# �SL
Da � e Of Crema t i.on v�ta�
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Time Cremation Started
1: to
Time Cremation Completed ( ; 5jp iM
Type of Container C L
Remarks /95L GR wp
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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
Audxwlzadon to Cremate
The undersigned requests and&Mcxtzes Pine View Crematorlum,in accordance with and subject to Its Rules and Regulations to
cremate the remains of.
I'I'S 4,g t:jA A A h 1'17 A
� fzM�✓ �� C�• pal (SOX)
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(Stree) (Cky) (tee) (ZIP Code)
who died on �- ! �f —_ day of dG i alo�r 20 0
at yes cVAl'Al r.J 1 104e; A f4CG ) d , f
(Place) ) -
Name and address of nearest Wing relative or name of person oulhortziing crometion:
( ) VAd )
Relatiormhip to the deceased 'U/ 0 Ili I
Name of Funeral Florae G-rCNA►� 1.• IC..i 11✓ Ff/AI en-N
IMPORTANT:
I represent that to the best of my Ivrowledg%the deceased(has) pacemaker.defibrillator.battery.battery peck,power
coil.radioactive Implant or radioactive device In his or her body.( )
I certify 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 remYved or may be destroyed.and agree to protect.defend and
same harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by of or oarrected with the cremation of said remains as drsch4 whether such claims or demands are or are not wholly
false or
t-- IS�r�P �tlG••.� Jae. �C�'
• (Address) `
( and Address of Relative or legal Representative)
Signed an this dater Za — 17 ,
Disposition of Cremated Remains
I hereby direct Pine View Cremauxl m to dispose of the cremated remains as follows:
mall to
Other anangemenis-Please spedfy: rL
H pulverization of cremated remains is requested,check here
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Revision:April 18,2007 1
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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 acceptenee.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 ti.ey 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 zither been removed or may be destroyed and agree to protect,defend and save
harn-,•ass Pine View Cemetery and Crematorium from any and all claims and demands
for logs of damages which may be made against them by reason of or connected with
the c: --rnation of said remains and/or disposition of said remains as directed,whether
such ims are,or are not wholly groundless,false or fraudulent.This authorization in
add i, n to a regular burial permit must accompany the remains.
3. All rc ,:ins must be In a casket or suitable alternate container.Caskets and containers
mus' a of a combustible material. No styrofoam or plastic containers will be accepted.
4. Any ~:,iac pacemakers,defibrillators,battery,battery pack,power cell, radioactive
Imp! or radioactive device must be removed from the body before any remains will be
acre, -A. -
5. Crec- t:ons will be completed within three working days(72 hours)of receipt of the
t Burn i"ransmit Permit and Authorization to Cremate Form.The cremated remains will
be r: d via Registered U.S. Mail within three days of cremation to the funeral home
har ; the service unless other arrangements are made.There will be a$30.00 charge
for t: 3rvice.
6. Crcr. ''on,Administration Costs and Recording Fees:
Adu: $330.00
Chi:. , (age 13 months to 12 years) $180.00
InfL. ;stillbom to 12 months) ` $130.00
Ov . Cremations(Weekdays) $480.00
Satu. Cremations a480.00
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