Baumgarten, Jack .C. O
p W E VY E OF QU E E9�5B
�', CEMETERY 1�
'QuxkCPR ROAD AND CREMATORIUM
(518) 74�4.4 6 SBURY' NEW YORK 12804
_ Funeral Director
Famel�h(l
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Gate
Of Cremation
Time Cremation L3U�
Started
Time Cremation Completed
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Type of Container
Remarks �� o�' l �- 5
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Town of.Queendmry
Piro View Cemetery and Crematorium
21 Quaker Road,Queensbury, Now York, 12804
Cemetery Of ice:(518)7454476,Crematorium:(518)745-4477
Authorization to Cremate
The WXWMWW ISOMIStS and aLithortzes Pit*View Cremalarksm,In accordance with and subject to its Rules and Regulations to
cremate the remain at
)3AUM SA Ji'A) MA
(SM)
/-s-xs- Sa reef') i A/& �J.Y I ;j/,70
(Sbw) (city) (SWIS) (Mp Code)
who died an YL- ae 11 day d U 20 0
at f-ffd "
(Ph") VWdress)
Name and address of nearest WAV relative or name of person auftrbftcremation:
(Address)
PAMOCOWtD the deceased
Name of Funeral Home n y n r-d L
IMPORTANT-
I represent that to the best of my kwwhxfM the deceased(hes)or(has no)pacemaker,defibrillator.battery,booty pack,power
cell.radioactive Implant or radioactive device In his or her body.(Circle One)
I cardly that I have IA power and authortiostion to arrange for the cremation of to 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
were harmless Pit*View Crematorkm from any and al delms and demands for loss or damages which may be awe against tam
by reason-d or connected with cremation of said norneks as directed.whether such claims or demands we or are not wholly
J(S!!P�and Addrl!�#Relative or Legal Representative)
IL an this dole: ZOO
Disposition of Cremated Remains
I hereby direct Pit*View Crematorium to dispose of the crameted remains as tlows:-
M.Al. W ; LLB
—
V
Other arrangements-Please sPoW.
If pU�iarkootlon of cremated remains Is requested.check hem
Revision:April 18,2007
Policies,R• ' Regulations
1. Pin- ,rematorium is located on the grounds of Pine View Cemetery.The
crer , operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrz Is for the acoeptance.of remains are necessary. Prearrangements are
nec -3r overtime or Saturday cremations.
2. A ation to Cremate'form signed by the nearest next of kin is necessary stating
tha' Nave the power and authority to arrange for the cremation of the remains
anc the disposition of the cremated remains,that any personal possessions
ha,. ,een removed or may be destroyed and agree to prated,defend and save
har 13 View Cemetery and Crematorium from any and all claims and demands
for i images which may be made against them by reason of or connected with
the -i of said remains and/or disposition of said remains as directed,whether
suc ,re,or are not wholly groundless,false or fraudulent.This audxAzation in
ad: .-egular burial permit must accompany the remains.
3. All ust be in a casket or suitable alternate container.Caskets and containers
mu combustible material. No styrofoam or plastic containers will be accepted.
4. An. 13cemakers,defibrillators,battery,battery pads,power cell,radioactive
im I bactive device must be removed from the body before any remains will be
as
5. Crc i11 be completed within three working days(72 hours)of receipt of the
Buy .lit Permit and Authorization to Cremate Form.The cremated remains will
be Registered U.S. Mail within three days of cremation to the funeral home
ha arvice unless other arrangements are made.There will be a$30.00 charge
for
6. Crc :ministration Costs and Recording Fees:
Ac $330.00.
Q. 13 months to 12 years) $180.00
In` )rn to 12 months) . " $130.00
O. nations(Weekdays) $480.00
Sa; :nations $480.00
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