St. Louis, James �O O
F QUEE9�5OUrPTHE VfE'4Y �.J
CEMETERY AND CREMATORIUM WAXER ROAD. Q(jEENSBURY, NEW YORK 12804
(518) 745.4.476 (518) 745-4477
Funeral Director LI« k
�i . Case#
Date Of Crem8t1.0n Q W n,�
Time Cremation StartedQ�
Time Cremation Completed
s.
Type of Container
Remarks
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remake of:
James F. St Lotzis Male
(Name) (sex)
14 Chickadee Lake, Lake Placid- NY 12946
(Street) (city) (Side) (Zip Code)
vwho died on 24th dayof November 2o08
at Adrk Medical Ctr. , Lake Placid, NY _ _
(Place) ( )
Name and address of nearest Wing relative or name of person authorafng cremation:
Mrs Barabard Whitney 150 Mill Pond Drive, Lake Placid„ NY
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral dome N. B.- Clark, Inc.
IMPORTANT: dOMNSOW,may, ,per,Power
represent that to the best of my Ivwwledge,the deceased(has)a(ties no)peoemsker,
cell,radioactive Implant or radioactive device In his or her body.(C:kde Clete)
I certify that I have full power and authorUstion to anange for the cremiedw of the remains and to dkec t 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 Crematorium from any and aU claims and demands for loss or damages which may be made agaktst them
by reason of or connected with the cremation of said remains as directed,whether such daims or demands are or are not wholly
groundlessfalse or fraudulent
2310 Saranac _Ave. , Lake Placid, NY 12946
(fin ) o ( )
150 Mill Pond Dr. , Lake Placid,NY
(Signature and Address of Relative or Legal )
Signed on this date:. 11/2 6/0 8
Disposition of Cremated ReMalre
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows:
Mail to
O&waffe tts_P spectiy- Picked tp by Ftlnera 1 Director
If pulverization of cremated remains is requested,check here xx
Revision:April 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.
2. A `Authorization to Cremate'Than 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 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 sage
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 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 accompany the remains.
3. Ali 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 pacemakers.defibrulators, battery, battery Pads►power 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. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made.There wig 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 (stilibom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00