Ashwood, Donald p F QUEE9�S3U2r
WE VIEW
TERY CEM
E AND CREMATORIUM
i��IJCER ROAD, QUEPNS9URY KEW YORK 12804
(5 18) 745.4476 (5 18) 745'.4477
Funeral Director
Name � orK Lt r
S�,wu`" Ca s e#� l
Dace Of Cremation _ G _ O
Time Cremation Started
1� 30
Time Cremation Completed 10 oc; A
Tyke of ContainerC,s
R e ma r'K sf fo r 2,�s
�.. , q `l
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745- 477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
DOLALD 11, vo '
(SOX)
Jy Go$R L F 14ILZ /fin GAkx- 44 /29916
(Street) (City) (State) (Lip Code)
who died on
I ,xT day of IAN►i/)12L__.-20 02
at 4n2�c lti�'fl1� a� � �Tz-2 •JA it AIAc L,9icE N>!
-' (Place) O
Name and address of nearest faring relative or new of parson authorizing cremation:
C 81AtS VAA)C-d' O, WIII,& ' L�OAC )"e'S
(Name) (Address)
Relationship to the deceased Gc
Name of Funeral home C�CL/t9 LA>tr
IMPORTANT:
I represent#0 to the best of my knnowiedge,the deceased(has) paomna�,�.be". y�,POW
cad,radioactive implant or radioactive device in his or her body.(Circe ne)
I certify that I have full power and autin xbmiion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View CrsmaWicmn from any and all cdaims and demands for toss or damages which may be merle against brava
by reason of or connected with the cremation of said remains as dkocted,whether such clelms or darnands are or are not wholly
groundless,false or fraudulent.
(Address)
($Igrrepae Tess of Re or Legal Representative)
S' this date. J 14N. Z 2.o G 9
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mail to .
2310 Saranac Ave
e lacid NY 12946
Ott arrangements-Please specify:
If pulverization of cremated remains Is requested,check here y
Revision:January 1,2009
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 $350.00
Children (age 13 months to 12 years) $200.00
Infants (stillborn to 12 months) $150.00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations $550.00