Tunney, Timothy TO O
PWE YIE QUEE9�SB l�
V' CEMETERY AND
ROAD, QUEENSBURY CREMATORIUM
(518) 745,4476 ' NEW YORK 1z804
(518) 745'•4-477
Funeral Director
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Time Cremation 10
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T : me CreR18CiOn
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Town of UueenMXMF
Pine View Cemetery 81710 txemmrffr .
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(5181745-4476,Crematorium: (518)745-4477
Authorization to Grenum
The u►Kiersioned requests and authorizes Pine view Crematorium,in accordance with and subject to Its Rules and Regulations to
(Namel (sex)
(S"0) (City) (State ( )
who died on - day of
at �p.a(t�S �t S SOiTi4 L-
( ) (address)
►.lame and address of nearest avbV relative or name of Person sudwrizkV aemalion:
(Game) (Address)
RelationsfuP to the deceased
Name.of Funeral tome
iMPORTAN T:
i represent that to the best of my Wmiedge,the deceased(has)or(has no) W.'� or,��', �'Pa Pmw
cell,radioactive imPlW or radioactive device in his or her body.(Cade One)
iced*thatiIra+refs0tmrreirreade�o � �rrrrlAs +uf�e ins�dloa t �iapa�itao of the
ae ne"d remains.d"any Pew P tOtery e'�erb w eaararredar a�be dedleo�awd agree�Pam.defend and
save harmless PbWVbwt]etoeUrtmfrfe■raeyw*U& ierrlorrri+artlearegRw �l + '�tharrz
by reason of orconnalerdwrihtba atsabt�airsas�ieetet.�e�ersnrbcfiwsardeeAendsaearaenotwhoty
grounamms,take or travoLOM
(Witness) (Address) -
(signature`w v Address Of or legal Representative)
L
Signed on this date:
Disposition of Cremated Remains
1 hereby drect Pine\raw Crematorium to dispose of the cremated remains as fob:
Mail to
other arrangements-Please specify:
if pulverization of cremated remains is requested,dm&here _
Revision:Aprd 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.
,4. A -Auttmonz mn to Cremate`form sigma by Vo rat next of kin is necessary sung
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 cremarion of said remaiirt andlor dk gtx)sMon of sW rarnafs as wed,whrether
such claims are,or are not wholly groundless,false or fraudullem 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 pacanakeis.deftiadjtors, batkWy battery pack poor 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. Ne#within three days of cremation to the fiwneraf 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 rrronths) $130.00
Overtime Cremations-(Weekdays) $480.00
Saturday Cremations $480.00