Rothlauf, Hilma L O
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O� F QUEE9�,-50UrPINEVIEWC ' v
EMl✓TERY AND CREMATORIUM
�7l3CFR ROAD, QUEgNSgURY. NEW YORK 1280,
(518) 745.4476 (518) 745*•4477
Funeral Director w'Fame
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Dace Of Cremati 5L
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Time Cremation Started
Time Cremation Complete
Type of Container
Remarks Cf��wi�/i j ieA
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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
Audvxizadon to Cremate
The mWersigned requests and authorizes Pine View Creemewum,in acoordance with and subject to Its Rules and Regulations to
M/1 of h la u Ewa le-
(Nam)am) (sue)
Z Rt ri RAP L .xe LuZ-e—?t /`Y /28Y(o
(Street) (may) (State) Rip Code)
who died on -Z(o day of UD ki 2003
at a, P,n S jE its ±b s.2rt&J
(Place) f (Adress)
Name and address of nearest living relative or name of person audxxu*rg cremation:
(Name) ( )
Relationship to the deceased S 0 r�. �
Name of Funeral Horne-)�MA, i L k;�—rev{ +fD IK-F
IMPORTANT:
I represent that to the bast of my Wwwledge,the deceased(has) (has ro aker,defibrillator,battery,battery pack,power
cell,radioactive Implant or redloective device in his or her body.
I certify that I have U power and a 9mrization to arrange for the cremation of the remains and to direct the dispoaidon of the
cremated remains,that any personal possessions have either been removed or may be destroyed.end agree to Protect,defend and
save harmless Pine View Crematorium from any end all deims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remain as directed,whether such claims or dernerds are or are not wholly
lees,false or freudulern.
Z •(.tiwtr St L� Cuze-��
(wnrness) O
ignature and of Relative or Legal Representable)
Signed on this date: ! I Z O$
Disposition of Cremated Remains
I hereby drew Pine View Crematorium to dispose of the cremated remains as follows:
Mau to
Other arrangements-Please specify: ►-t J—,e� -In `1
if pclverara=of cremated remains is requested,check here
Revision:April 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 (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00