O'Neil, Jennifer L O OF QUEE9\�SBUrRPWE V1 `J
EVY CEMETERY AND CREMATORIUM
QU'AKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4-476 (518) 745-4477
_ Funeral Director �><4 �r
Name J2nn � Qir
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Date Of Cremati.on
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Time Cremation Started
Time Cremation Completed
Type of Container �,;;�
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Remarks ZN
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Town of Queenstwry
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 128M
Cemetery office:Sig-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The umlersignea requests and oulkwotimm 1Pka MOU Ooenxillouaa,in a000rCbmCe WAIT god stebpCt to its Rotes and Reputations to
cremate the remains oh.
Jennifer O'Neil Female
(Name) (Sex)
229 Diamond Point Rd. , Diamond Point, NY 12824
(SOW) PLY) (slate) (ZIp code)
who died on 19th dayof November W08
at-Glens Falls Hospital, Glens Falls , NY
(Place) (Add)
Name and address of nearf--it kving relative or name Of Person auhart231V awnatton:
Julie O'Neil 229 Diamond Pt . Rd. , Diamond Point
(Name) (Address) - -
Relationship to the dew Mother
NameotFuneralHome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the hest of my lam,the deoessed(has)or Gras no)pacemaker.delilxiamW or any other battery operated
device In his or her body- (Circle One)
I certify fait power alAmft lion to arrangq for rise aattmon&the r mlaft and to direct the d lion of the
aWKftd s ernaitm Vial any possesslors tmm a been re allow d or may be dami and agree to protect.defend and
ve harmless Pine View km any and all damns oddemands far loss or dmiages which may be made against them
by reason of or connected. thus ot sad3 runs as drecleci vAlBOW such dam_S or dezralrts ate or are not wi3ony
groundless,false or
� a
rx �
( Address of Relative or Legal Representative)
signed on this crate: November 24 , 2008
Disposition of cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
man to
Other arrangements-Please specify.F H will pick up
if pulverization of cremated remains is requested,cheoc here X
Revision:4U- 2@f74
/B aAl 07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the Ards at 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 cxemations-
2. A "Authorization for Cremation's:Egned by the nearest next of kin is necessary stating
that they do have the power and autt=ity 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 cremation of said remains and►or dis on of said remmins as directed,whether
such claims are, or are not wholly groundless,false or frauddlem This authorization in
addition to a regular burial permit must any the reffiains.
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 otter baUery operated devices must be removed
before any remains will be asx .
6. Cremations will be corrtpteted w0iin ft a woddr:g days(72 tours)of receipt of the
Burial Transmit Permit and Auftn zation to Crime Form.The cremated remains will
be mailed via Registered U.S_ Mail v4diin three days of cremation to the funeral home
handling the service unless other arrangements are made_There will be a$?&IQ charge
for this service. ,
6. Cremation,Administration Costs and Recording Fees:
Adult 330,
Children (age 13 months to 12 years) 8� 190-
Infants (stillborn to 12 months)