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(518) 745'.4.477
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Town of Queensbury
Pipe View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518) 745-4476, Crematorium-. (518) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pine View CrematOr;Ufll.in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Maria T. Dol
(sex)
-Mi-Li t a r v -Raad-J�a-k-e- P 1 acd-d4-.--N Y L29 4 6
Y) (state) (Zip Code)
who died on
allUbJ-ei-n-Mar r-y-Cen-t,�� L&5--.1a-1� -Kil-itax-y-R4-,-Lake Placid, NY
(Place)* (Address;,
Name and address of nearest living relative or name of person authort7inq cremation:
Nrs Maria ZieQler 3.0 1,jnoiL -r-r --Lane-Laka-Pi-a-cid, NY
---'-' (Name) (Address)
Relati6nsl`00 to the det*6sbd a i-Ight e
Name of Funeral Home-M. B. Clark Inc.,.
IMPORTANT: s)or.',has no}pacemaker,defibrillator or any other battery operated
I represent that to the best of my fmo"Aedge,the deceas&j TO
device in his or her body. p-cle One)
I certify that I have full power and autho0zation'Zo arrange he cnernallon of the remains and to direct the disposition of the
cremated remains,that any personal possesslonslvve ehher been removed or may be destroyed.and agree to protect,defend and
save harmless Flhe Views Crematorium from any and all dalms and demands for loss or damages vA*:h may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundlesslake or fraudulent.
10 P Lake-
, P-Lacid, NY 12946
'Ijuli 2
(Witness) (Address)
-o-wJD-er-r-y-L.ane-,-.Lak-e Placid, NY
(Signature and IvIresfof Relative or siege`Repnesetitative)
Signed on this date: Jan. 29, 2009.
uf Cremated Remains
I hereby direr Pine View Crematorium to dispose of the cremated remains as follows:
Mail to,-KB---C.l.a-r-k.,r T-n-c.......2-3.1-9-,..-Sa-r-&n-ac---AV-0---
Lake P1aq-j,0-,-KY-12-946
ff pulverization of cfernaled;-arTlains is requested,ci*4
Revision:January 1,2006
S
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 Saturday cremations.
2. A "Authorization for Cremation" signed by the nearest next of kin is necessary stating
that they do have the power and authority to amange 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 andior disposition of said remains as directed, whether
such claims are, or are not wholly greundless,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. Cardiac pacemakers, defibrillators or rather battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within tl?ree worVing 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. Maii 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 $325-00
Children (age 13 months to 12 years' $175•00
Infants (stillborn to 12 months) a125.00
Overtime Cremations oAfeekdays) $450.00
Saturday Cremations $450.00