Bentley, Paul OF QUEE9�,5(3U2r
PLNE V'EW CEMETERY AND CR
QUhKE-R ROAD, � EMATORIUM
QUEENSBURY, NEW YORK 12844
(518) 745.4-476 (518) 745'-4477
Funeral Director
Name 9V I u -
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Date Of Cremation ` )
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Time Cremation Started
Time Cremation Completed IHI
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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 remains of:
(Name)
s�YD "4 4rnj A4 Opj�KAe_JV laqffl,
(Street) (C ) (State) (Zip )
who died on day of 4 1,� 7,bL'� 20 0,9
(Piece) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) I (Address)
Relatiorrshrip to the deceased C5f)n
Name of Funeral Home f f'1�.(_f( Q Yjp
IMPORTANT:
I represent that to the beat of my Ivowledge,the deceased(has)or(Eras no)pacemaker.deflbrillator,be".battery pack,power
can,radioactive Implant or radioactive device in his or her body.(Cirde One)
I certify that I have Tull power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personnel poeeeeaions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any-and all claims and demands for loss or dam which may be made against them
by meson of or connected said as directed,whether such claims or demands ere or are not wholly
ground or
(Address)
0
(SW6&Ke and Address ofR IetNe or Legal Represertative)
Signed on this date:
Disposition►of Cremated Remains
I hereby direct Pine View Crematodum to dispose of the cremated remains as follows:
Map to
Other arrarrpemeMs-Please specify: rta I C&5-e- -10 f ltJrn(`� y�h V.e
If pulverization of cremated remains is requested,check here _
RevWori:April 18,2007
Policies, Rules and Regulations
1. Pine mew Crematorium is locatedoon Pine
to 3:30pm Prior telephone
crematorium operates Monday ugh Friday from 7 OPrearrangements are
arrangements for the acceptance of remains are necessary
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
Adult
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480•00