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Lawton, William %-/ OF QUEE9�St3U2r "E "Evv CEMZTERY AND CRE qtA ER p " - Q(,igp„NSg�Y MATORIUM ?YEW YORK 12804 (518) 745.4476 (518) 745•4437 Funeral Director dame 6<I�12r Date Of Cremation S'�V 11(tn. r 3 Time Cremation Started Time Cremation Completed Type Of Container awe; f c K �S T Remarks NHS ��- T)h 2 ti o---------------------------------- �� ��rp� ----------------- ------------- • � 5 sv 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 remake of: WILLIAM LAWTON MALE (Name) (Sex) 44 Hawthorne Rd. , Hanover, MA 02339 (Street) (City) (fie) (23p Code) who died on 1st day of December 2(p8 at AMC—TJihlein Old Military Rd. , Lake Placid, NY (Place) (Address) Name and address of nearest living relative or name of person authorizing crametion: Mrs. Janet Mellor 712 Averyville Rd. , Lake Placid, NY (Name) (Address) Relationship to the deceased Daughter Name of Funeral Home M. B. Clark, Inc. -_Lake Placid, NY IMPORTANT: I represent that to the best of my knowledge,the deceased(has)or(has no)pecernalter,defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device In his or her body.(Ck de One) I certify that t have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the cremated remake,that any personal possessions have either been removed or may be destroyed,mid agree to protect,defend end save harmless Pine View Crematorium from any and all clams and demands for loss or damages which may be made against them by reason of or connected with ft cremation of said remains as directed,whether such daims or demands are or are not wholly groundless,false 4r frautktlent. L/ ,'/1 2310 Saranac Ave.;, Lake Placid, NY 12946 (,--� ? (Address) 712 Averyville Rd. , Lake Placid, NY 12946 (Signature end Address of Relative or LVal Representative) late: Dec. 1 , 2008 Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify:T o b e picked up by daughter, Janet Mellor Dec. 4, 2008 If pulverization of cremated remains is requested,check here Vy. Revision:April 18,2007 Policies, Rules and Regulations 1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The crematorium operates Monday through Friday from 7:00am 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 authorisation 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 styrofo®m or plastic containers will be accepted. 4. Any cardiac pacemakers,defibrillators, battery, battery peck, 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 crenv3don 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 (stillborn to 12 months) $130.00 Overtime Cremations(Weekdays) $480.00 Saturday Cremations $480.00