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i KER ROAD. QUEENSBURY, NEW YIORKO 1R 804
(518) 745.4476 (518) 745.4477
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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 aulhortzes Pine View Crematorium,in accordance with and subject to its Rules and Reguiations to
cremate the remains of:
George A Beattie Male
(Name) (sex)
19 Newman Rd. , Lake Placid, NY 12946
(Street) (City) (fie) (Zlp Code)
who died on 2 9 t h day of Nov. , 2o0 8
at AMC at Saranac Lake, NY
(Place) ( )
Name and address of nearest lMng relative or name of person auftr6drng cremation:
Catherine Boyer 61 Summer St. , Lake Placid, NY 12946
(Name) ( )
Relationship to the deceased D a u g h t e r
Name ofFunwalHome M. B. Clark, Inc. , Lake Placid, NY
IMPORTANT:
I represent to to the best of my knowledge,the deceased(has)or(has no)pacemaker,defi"ator,betwy,battery peck,power
cell,radioactive knplard or radioactive device In his or her body.(Cirwde One)
I certify that I have full power and authorization to arrange for the aemetlon 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 Crematorium from any and all claims end demands for loss or damages which may be made against them
by reason of or connected with the asmation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
_ 2310 Saranac Ave. , Lake Placid,j NY 12946
(Witness) (Address)
61 Summer St.;, Lake Placid, NY 12946
( ignature and Addre&af Reladve—artegal Representative)
Siared on this dam: Nov. 30, 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Maiito M. B. Clark, Inc.
2310 Saranac Ave. , Lake Placid, NY 12946
Other arrangements-Please Spew.
if pulverization of cremated remains is requested,check here xx
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: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 miners
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4- Any cardiac diac POCemakem 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 tome
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