Lee, Barbara F
YTEW
CEM'�TtRy ANID
PWu R ROAD, QUEE CREMAT
NSBURY, NEW
Y ORIUM
(518) 745.4476 oRK �Zsoa
(518) 745�•4-0�7
n Funeral Director r)
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TOWN OFOUEENGBURY | '
PINE VIEW CEMETERY �
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CREMATORIUM '
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�Quaker Road, Oueensbury. New York 12804 �
Phone (518) Crematorium 745'4477 (if no answer)
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Cemetery745-447G
AUTHORIZATION TO CREMATE �
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The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains ot
�
(STREET) (CITY) (STATE) (ZIP CODE) E,:
who died on 4-6 day of 2o 6f
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
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Relationship todeceased
Name of FuneralHome 13
IMPORTANT
knrin itorher
| ,cp/ asntthathothobastofmyknow\mdge. thedacaamedh�� anenna
body. (CIRCLE ONE) !. .
| oertif/that l have the full power and eutUorizaUonto arrange for th � of the
r�'.66ins and
tu direct the disposition of the cremated remains, that any personal possessions have el,
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narnov,dor may bedostnoyad and agree to protect, defend and save harmless Pine V/�vY
Crenn"p`ohurn�ornany and all
'claims and demands for loss or damages which may bm d
f connected the cremation remains �g directod.Whether
aQeinstth�mbyr��s�n � �r Conn �
an. fo|aeor�roudu�enL
such claims nr demands are or are not wholly ground|e �
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DISPOSITION OFCREMATED REMAINS ;
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I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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Other arrangements-please specify:
|f pulverization of cremated remains ia requested, check here
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POLICIES, RULES AND REGULATIONS �
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1 The crenn8tohunnvv|8 be open for cnnrnadons 5 days a week 7�OOA.KA� - 3�3D P.M. K��nd8y'
ntsoanbennodeforSsdurday� .�Preorrangpnnents
Friday. NoHo|id�ysorSundoyu. or/angerna
by telephone for acceptance of remains ionecessary.~ ||
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quak�r:Road,
Town ofOuaenabury 1
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3. An t� non norc/emuou, properly signed by the ..~~.~~^ next _ kin — other
person stating that they do have the power and authority to arrange for the cremati6' of the
remains and to direct the disposition of the cremated remains, that any personal pos. sessions
have either been removed or may be destroyed and agree to protect, defend and s,�ve
harmless Pine View Crematorium from any and all claims and demands for loss or(Jamages
which rnay be made against them by reason of or connected with the cremation of i said
remains and /or disposition of said remains as directed, whether such claims or de.,,.'riands are,
or are not wholly groundless, false or fraudulent, This authorization in addition to a regular
burial permit must accompany the remains.
4 All remains must oe encased mu casket u' suitable alternate container. Caskets and
containers must beof combustible material. NnSbrofoamor plastic containers miNbe
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accepted, ,
5 Thequestionno|ativeLooardiacpacernaknrsmuotbeansweredonthemuthOhzat|umto
cremate form hpfonathe remains will be accepted.
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G Unless other arrangements are made the cremated remains will be mailed via Reg,i,stered
U.S. Mail within three days of cremation to the funeral home handling the service. There will
bea $20.OD charge for this service. '|
Cremation, Administration Costs and Recording Fee: Adu|t$225.DO Children (age 138nonthsto
12yaoce) $115.00 Infants (stillborn to 12 months) $75,00
- Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Fhd . �
Cremations done on Saturdays will be charged the additional $5O.00 �
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