Smith, Brian OF QUT:'
P W E V1 E 4Y CEME Eg�B `—�
TERY AND r�
QUA CREMAKER ROAD, QPNS$ TORIUM
(518) 74QUEF- URY' i�w YORK 12s04
(518) 745.4477
Funeral Director 1
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Date O! Cremati.on Case# l �
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Time Cremation Started
f2 3u P T ,.me Cremation Completed
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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
Authorization to Cremate
The undersigned requests and audwrizes Pine View Crematorium,in accordarroe wdtt and st&Oct to its Rtdes and Regulations to
cremate the remains of.-
Brian K. Smith Male
(Name) (Sex)
120 Maple Street, Rutland, VT 05701
(Street) (CRY) (fie) WA )
who died on 4 t h day of Oct. 20 0 8
at Rutland Regional Hos , Rutland, VT
(Place) (Address)
Name and address of nearest wing relative or name of person autttWIZIM c reffsw n:
Laura Armstrong, 1994 Rt 30N, Bomoseen, VT 05732
(Name) ( )
Relationship to the deceased Mother
Name of Funeral Home
IMPORTANT: Wzsz no 'motor or any other battery operated
i represent that to the best of my knowledge,the (��f�(� )
device in his or her body. (Ciirde One)
I certify that I have full auftt dnMon to anw gs for the cremation of the remains and to direct the disposition of the
cremated reams any possessions have efflier been st
n removed or may be destroyed.and agree to protect.def end and
save he ne view ematomrm from any and a8 dams and demo for hm or damages which may be made against them
by of or watt the cremation of soli fernains as dureci3ad,whether such t Or demands are or are not wholly
9 false
(Address)
X Same as above
(SWatwe and Address of ReIaW or Legal Representative)
5igneo on tnis pate: 10-7-0 8
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
marl to
Other arrangements-Please specify: F H will Dick up
If pulverization of cremated remains is requested,d*ck here X —
Revision:49 "
18 07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"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 mains
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 fnxn 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 any 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. Cardiac pacemakers,defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 lours)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 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $38@:Ot o �
Children (age 13 months to 12 years) $350 W /90- `'-.>
Infants (stillborn to 12 months) t"'
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