Levesque, Catherine OF QU
PW VIEW
LNE pEMETERY q
NrD CREMATORIUM
(518) 74�44 6 SHURY tMW YORK 12804
(518) 745.4477
Funeral Director
Fame
Date Of Cremati.on Case#, f
Time Cremation .�OL
Started
7; as �
Time Cremation Completed
1.11
y 36
TY?e of Container
Remarks '` (��
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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 authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the mains of:
eA eIles I ve-- ��p
(Name) (Sex)
( ) (City) (State) (Zip code)
who died on day of SAN 0 A d'``/ 20_Qq
(Place) (Address)
Name and address of nearest living relative or name of person authomng cremation:
T4G-9F4-'C;ut- A Aif-- Iq S y,*-A,e- Avg G/-,,Js �� may. 1ad:Vj
�( �e) (Address)
Relationship to the deceased CI( i e
Name of Funeral Home 9 uLA 4 /. - V.��y
IMPORTANT:
I represent that to the hest of my knowledge,the deed(has) er,defibrillator,battery,battery pack.power
cell,radioactive implant or radioactive device in his or her body.(C One)
I certify that I have full power and authorization 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 Crematorium from any and all dawns and demands for loss or damages which may be made against them
by 4"connktN the cremation of said remains as directed,whether such claims or demands are or are not wholly
or t.
�a x-Y4P
( )
lure and Address of Relative or Lftal Representative)
Signed on this date: O �2 Q 0 I
Disposition of Cremated Remains
I hereby direct Pine View C t pose of th cremated remains as follows:
7
Mail to I , ~
Other arrangements-Please spec Ify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
r
Policies, Rules and Regulations
ry.The
1. Pine View Crematorium is located on
h Fthe riday from 7:Orounds of r0amne �t 3:30pmew ePri telephone
crematorium operates Monday 9 prearrangements are
arrangements for the acceptance of remains are necessary•
necessary for overtime or Saturday cremations.
2. A "Authorization to Cremate"form signed by the for the cremation ne)d of Win is necessary
mains stating
that they do have the power and authority arrange
and to direct the disposition of the e cremated destroyed
and agree t proains,that any tect,ad�P�e
have either been removed o y
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 autition in
addition to a regular burial permit must accompany the remains.
3. All remains must be in sesuitable
ra � �tal
must be of a combustblamall No tyofo �pla�containers be nd containers
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. Cremation 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 Rrade•There will be a$30.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $36A
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