Loading...
Duell, Gerald �Q Q � . ROADT�RY (518) 745Q4476S8 NBw YO CREMATORIUM (S 18 YOR 80a 745'.4.477 Funerel Director ��t:r�• ; Ic ; � T e b 17 � :C 7 rematiOn Started Ire : rem ° ti °n Completed % �i� icJ Container . M = I uc l r 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 crem a the remai of: accordance with and subject to its Rules and Regulations to (Name) eo� OQ P� (Sex) (street) City) (state)who died on (Zip Code) day of L C� ( lace) - / © ,.7 at ZO . (Addy ) Name and address of nearest living relative or name of p / Person authorizing cremation: �A rt7 (Name) L (Address) Relationship to the deceased l Name of Funeral Home Z227 IMPORTANT: I represent that to the best of my knowledge,the deceased ( cell,radioactive Implant or radioactive device in his or her ) as ¢ emaker,defibrillator,belt body.(Circle One) aY,battery pad*,power I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition cremated remains,that any personal possessions have save harmless Pine View Crematorium from any and all deims andndemands for aY be destroyed,and agree toPr of the ect defend by reason of or connected with the cremation of said remains as directed, loss or dam g y made against them and ground ,false or fraudulent. whether such claims Or are or are not wholly (Address) -', 7 N I 1��f� ('s- (4Signatureand Amc © � P W ` 1 �' Address of Rela've or Legal Representative) Signed on this date: © Disposition of Cremated Remains I hereby direct Pine View Cremelamm to dispose of the cremated ramans as follows: Mel ID Outer arargernents-Please specify �.>�r>Zallt)n Jt meted t9gV*s is requested,ched*here �1151a1:Jtlrtuay 1,2M Policies, Rules and Regulations from 7:OOam to 3:30pm. Prior telephone e Pine View Crematorium is located on h F grounds of Pine View Cemetery. are 1' rates Monday throng prearrangements crematorium operate Lance of remains are necessary• arrangements for the acceptance cremations. necessary for overtime or Saturday stating °Authorization to Cremate"form signed by the nearest next of kin is necessary 2. A he power and authority to arrange for the cremation of the remains that they do have t Po that any personal possessions and to direct the disposition of the be d ate remains,agree_to protect,defend and save have either been removed or may Crematorium from any and all claims and demands harmless Pine View Cemetery be made against them by reason of or connected with for loss of damages which may lion of said remains as directed,whether the cremation of said remains and/or disposition claims are, or are not wholly groundless,false or remains. addition This authorization in such must accompany addition to a regular burial Permit remains must be in a casket ers or suitable alternate container.nta containers wanbea�pted. 3. All rem rofoam or p must be of a combustible material. No sty power cell,radioactive Pacemakers,defibrillators, battery,battery Pack, 4. Any cardiac pa before any remains will be implant or radioactive device must be removed from the body accepted. 5. Cremations will be completed within three working days(72 hours) of receipt of the Burial Transmit Permit and Authorization to Cramdays ate Form.The cremated remains will of cremation to the funeral home be mailed via Registered U. S. Mail within three y handling the service unless other arrangements are made.There will be a$30•�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) s $ .00 150 Overtime Cremations(Weekdays) $55 00 Saturday Cremations