Fissette, Roger O
pUVE V1EV' CEMETERY AND CRE
QU'A _ER ROAD, QUEE NEW NSBURY MATORTU4
(518) 745.4.476 YORK 1280
(518) 745'•4-477
Funeral Director V/
Fame Ro er tk RtLI
Case#
Date Of Cremation
`
Time 10U�
Cremation Started
Time Cremation Completed
Type of Container �looa
Remarks
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10
?Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York. 12804
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Au#wrizadon to Cremate
The undersigned requests and&*at es Pine View Q`re namium,in a000rdmw with and Subject to Its Rules end Reyulatbns to
awnwe the remains at
O (ter) (sue) (PJp Code)
who died on day 20
d i
(�� (Address)
Name and address of nearest Wft relative«name of person auarorift cremation:
r)1.� _faek) 1&> -on
Reiattorm*to the deceased Val
Nerve of Funerel Hwo ,7 ,�Ai
IMPORTANT:
I represent that to the beet of my ivwwi mV%the deceased(has)or 0M no)peceme w.deftMaW.battery.boY Pam,pmw
oe1,radoecdw inObtt or radbeaive device in his or her body.(Ckb One)
I cw*that I have U power and au taketion to wmnpe for the aenratim of the remains and to dked the disposition of the
aenrated remains.that arty pw=W powessbra have either been removed or may be destroyed,and agree to proteM defend and
seers harmless Pine View Cmnatorium from any and al dalms and demands for bss or damages which may be made ages w them
by reason of or cmno ed wkh the aeMadon of said remebs as d racb4 whether such dW=or demands are or are not wholly
falee��� n ,
(Sign A=and Address of RelsOm or Legal Repressrwive)
Signed on ttas dates
Disposition of C n mated Rwnains
I hereby dred Pine View Crematorium to dispose of the cremated remains as folowc
Mats to
Other wmngwnerft-Please speafy: Ic j 014 AV ptli,F jvj
ff pulverizatbn of cremated remains is mWeded.check here
Revision:Apt 18,2007
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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'form 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 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 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. 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 pacemakers,defibrillators,battery,battery pack,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 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 (stillbom to 12 months) ' $130.00
Overtime Cremation(Weekdays) $480.00
Saturday Cremations $480.00
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