Sheffield, Gilbert 4 .
r-r
-1� O O
F QUEE9�SBUr)�J'Y7E'4Y
CEMETERY AND CREMATORIUM
�' 10ER ROAD, QUBENSBURY NEW YORK 12804
(518) 745.4476 (518) 745*-4477
II FFuneral Director_ pppp
Name � �t
�l � (�l(`� Sh C j
Ca s e#, ��3
Oate Of Cremation ��C
2 vo
� $
Time Cremation Started �cC)
Time Cremation Completed
Type of Container Ij00
Remarks « W � ZND
I
I
� Z v� ,
I
Z
z�Ph
--------------
I
i
I
i
i
it
. I
i
i
_ . 3L3.
fi TOWN OF QUEENSBUR.Y
j PINE VIEW CEMETEPY
&
i
CREMATORIUM
Quaker Road, Queensbury, New York 12804
phone (518) Crematorium 745-4477 (if no answer'
Cemetery 77 45-44%6
1 AUTHORIZATION TO CREMATE
[he
undersigned requests and authorizes PineView Crematorium. in accordance with andsubject
s Rules and Regulations to cremate the remains a Male
(SEX)
(NAME)
�J 89 Greenwood St-, Lake Placid, �AT2946 (ZIP CODE)
3 (STREET) (CITY) (S
j day of December
,who' died on 5th
Adk Medical Center, Saranac
i at (ADDRESS)
II (PLACE)
me of person authorizing cremation:
Nameiand address of nearest living relative or na
ld 3524 Grand Magnolia Placid, Valiico FL
Richard Sheffie 33596
I
Relationship to deceased
2310 SaraL . �T np Lake PlasLd, NY
�a
Name of Funeral HomeM B Clark, Inc. 12946
Il
11rAPdRTANT knowledge, the deceased has c as no pacemaker in his or her
I represent that t the best of my
I body.;
I certify that! have the full power and author�tsothatarrange ersonal Possessioon of the remains and
ns have either been
If to direct the disposition of the cremated rem
es which may be made
removed or may be destroyed, and and demands fare{oss or damages fend and save harmless Pine sew
against them from any and all claims of said remains
against.them by reason of or connected with the
false or fraudulent,
directed, whether
such claims or demands are or are not wholly groundless,
2310 Saranac Ave. Lake Placid NY 12946
(WITNESS (ADDRESS)
Lake Placid,i NY
(SIGNATURE OF RELATIVE O EGAL RCP. AND ADDRESS)
2 3, 2003
Signed on this date:_ Sept.
II
i
DISPOSITION OF CREMATED REMAINS
I hereby_direct Pine View Crematorium to dispose cf the cremated remains as follows:
,ail to
iher arrangements-please specify: 4.1c �_�V
If!pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3.30 P.M. Monday-
Friday, No Holidays or Sundays, arrangements can be made for Saturday. Pre-arrangements
by telephone for acceptance of remains is necessary.'
2 Pine view Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
3jAn authorization for cremation properly signed by the nearest next of kin or other authorized
person 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
haveeither 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 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 or demands are,
or are not wholly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
contaiiners must be of combustible material. No Styrofoam or plastic containers will be
accepted.
5.� The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
�i
6. Unless other arrangements are made the cremated remains will be mailed via Registered
U:S. Mail within three days of cremation to the funeral home handling the service. There will
be a V5.00 charge for this service.
C I matioh, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
1 ,years)'$150.00 Infants (stillborn to 12 months) $100.00
it
i
dditional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
C emations done on Saturdays will be charged the additional $50.00.
I
i
i