Abare, Leonard 1 Q
OFF
PLNE YYEW �J� 3 U
CEM1~TERY A� CREMATOR
� '� ROAD, Ql1EENS$ CUM
(518) 745.4476 URY' TIEW YORK 12804
(518) 745'.4g77
Fuln,eral Director Fame j 7
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I HEREBY EXPRESS TO MY SURVIVORS MY EARNEST DESIRE AND REQUEST THAT ON MY DECEASE MY BODY SHALL
BE CREMATED AT PINE VIEW CREMATORIUM, ON QUAKER ROAD, TOWN OF QUEENSBURY, NEW YORK AND FURTHER DO HEREBY
ORDER, DIRECT AND AUTHORIZE SUCH CREMATION.
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(Signed) r0�
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(Address) 6 S 5-494))'0lZ b
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Dated 104109
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TO BE ENTRUSTED TO THE SIGNER'S EXECUTOR OR NEXT OF KIN
(Return copy to PINE VIEW CREMATORIUM, Quaker Road, Queensbury, N.Y. 12801)
02'/12/2009 22:03 15184942948 BARTON MCDERMOTT FHN PAGE 03
Town of Queensbury
Pine View CaM&tmy and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Csme►efy Office; (518) 7454476, Crematorium: (518)745-4477
Authorization to Cremsta
Thecremate t�� ��9 end&Avrtm Pine Vlsw Crwnatork",in OcmderxO wkh pnd subJeCt b bs Rules end riepuletbrle to
(Name)
(CKY) (State) )
who died on day of =!�/ C
74.
at
Name and eddrees of nearest relarlw or norm of parson @uftrWmpmn/ scion 'p
Relet meMp to the deceased
Nome of Funeral Home /�n U
IMPORTANT:
I repre®ent that to the beet of ny bwMedga,the deceased(has) ulcer,deflbrNlator,battery,ba larY fah power cell,m dloaclim hnpiard or radioactive device in his or her body,
1 cWW that 1 haw full power end auMrorWMw to emerge for the cremeeion of the rernakrs and to direct the disposition of the
crameted rernakue,that any personal Poesessimm hove ellher been removed or may be destroyed,and agree to protest,defend end
save harmless PUw View Cfenlstorium from any and all claims and dwnwxb for lass or damages which may be made against them
by reason of or connected whh the sent Mm of sold rmtmlrts m II RAN .whelhw such claims or dernande are arms not%"
m/ �c�(,i.�! Po s�S'/9�Foa 44 IUe�,�� xt�I r zarZ
( ) J
wMmurs of Reletive or Legal RepreserutaNva)
signed on this daMe D
Diapmkion of Cremated Remains i
I hereby direct Plus View CmnModum to disposed the crarnMod remains ere Mlows: (/
Mimi to
Other errengements-Please WOW
if pulvertaetion of cremated mna to Is re0uemd,Check hens
Reviioon:Jsnusry 1,2009
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 remains of:
(Flame) (Sex)
treat)
(City) (state)�Ip
who died on day of � �`> 2O/1
at f 17 / G =�`
( Ce) ( ress)
Na and address of nearest�lily' relative or name of person authoraing cremation: ,,,,
(Name)G .�` �? ( ) lwt'LT�'�rU A-
Relationship to the deceased
Name of Funeral Home `� C
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no maker,defibrillator,battery,battery pack,power cell,radioactive Implant or radioactive device In his or her body.( )
I certify that 1 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 claims and demands for loss or damages which may be made against them
by reason of or Connected with the cremation of said remains groundless,false or fraudulent. as directed,whether such claims or demands are or are not wholly
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
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
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
crem
te the
a/lYIGtC air of
/(Name)
��cz ,,", � c x
(Street) (City) (State) (Zip Code)
who died on c day of l 20df
(Place) (Address)
Name and address of nearest Iry relative or name of person authorizi1 mremation:
ol
(Name) (Address)
Relationship to the deceased
Name of Funeral Home C �'Z
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has maker,defibriliator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.( ne
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 claims and demands for loss or damages which 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
grou fa udulerrt. ..
1 ,< Poi es-
(witness (Address)
ignature arid A of Relative or Legal Representative)
Signed on this date: z2 Z'�)
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
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 Fomi. 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