LaHart, Robert OF QUEErV,5(3UTry
PINE "qEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW PORK 12804
(518) 745-4-476 (518) 745.-4477
Funfferal Director
\'ame
C a s e# Cr��
Dace Of Cremati.on
If ?0ov
Time Cremation Started
Tame Cremation Completed its P tl
TYPe of Container Li
Remarks
11;3 h ---------------
id P
r
a•
^ j
~.`^~.. `.~.`.... � '
[�������Mc�QR�V��h ' |
`. '—'_' �
Cemetery 745-4476
� |
AUTHORIZATION TO CREMATE
|
The undersigned requests and authorizes Pine View Cnemahzhum, in accordance with apd subject
to its Rules and Regulations Lo cremate the remains of:
Robert L. LaHart Male
(STREET) (CITY) (STATE) (ZIP CODE)
12tb October, 08
who died on day of
20
at Adr 'k Medical, Saranac Lake, NY 2983
Name and address of nearest living relative or name of person authorizing cremation:
Jerrilyn Johnson, 110 Parkside Dr. , Lake Pla cid, NY ,,
(PLACE) (ADDRESS)
�
Relationship to deceased
Dangbter
Name of Funeral Horne »« B Clark, Inc. , 2310 Saranac Ave.,, id, 0Y
�
�
IMPORTANT
| represent that to the best ofnly Knnwledge, the deceased has orhas no pacemaker inlhis; or her
body. (CIRCLE ONE)
`
I certify that I have the full power and authorization to arrange for the cremation of the r6nnajns and
to direct the disposition of the cremated remains, that any personal possessions have ellhbr been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Vii-aw
Crematorium from any and all claims and demands for loss or damages which may be M.' ade
against them by reason of or connected with the cremation of said remains as directed,.�Vhether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WFTRr=SS) (ADDRESS)
��Parkside Dr. , Lake Placid, NY
_4ATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date�
�
,
�
� /
`
'
�
DISPOSITION QF CREMATED REMAINS
�
`
i hereby direct PineV�wCrennatohurnhodiopoa�ofthaon*n�atadnema�nsasfoUo�s
Mail to
�
, .
Other arrangements-pleasespecify:
if pulverization of cremated remains |o requested, check here
__-___ ..
\
�
,
POLICIES, RULES AND REGULATIONS
`1 The crematorium will be open for cremations 5 days a week TOO A.KA. _ 3:3Dp.KA. M-,oddoy_
ntaman be made Pr��nahgpnnents
Fhday� N� Holid�ysor8undoya. a��ngecne ,
by telephone for acceptance of remains isnecessary.° '|
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quake,' r'Road,
Town ofOueensbury i
/
3 An authorization for cremation properly signed by the nearest next of kin or other o hhzed
person stating that they do have the power and authority ho arrange for the U e
remains and to direct the disposition nf the cremated remains, that any personal possessions
t ot defend d $
' PinaViaCrematoriumfromanyandaU o|ainn ave either been removed or may be destroyed and agree to �sanddemandofnr |osso[
amay
`~ �a
harmlessi~' ''' xv aybemod� agamstthembyraamonoforonnnaotodwdh<he cremation of said
remains^ � end /or disposition of said rernainsas directed, vvhethersuch c\mirnoorde�ndndoare,
or are^ ctvVho|hground|ess. fa|sen[fraudu|8nL This authohz21tionin addition hoa'peQu|ar
burial permit must accompany the remains.
4. All remains must be encased in8 casket Or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers vvxli be
1
accepted,
5 The question relative to cardiac pacemakers must be answered on the authorizaticb to
cremate form before the remains will be accepted.
8. Unless other arrangements are made the cremated remains will be mailed via R
U.S. K8oU within three days of cremation to the funeral home handling the service. Th ere will
bea $20,OO charge for this service. .i
Cremation, Administration Costs and Recording Fee: Adu|tB22S.00 Children (age 13lnonthshz
12yearg) $115.00 Infants (stillborn to 12 monthu) $75.O0
^ Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Fridai.
Cremations done on Saturdays will be charged the additional $5U.OU.
'
,
� '