Safka, Frederick To o Qu
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P LN E VT E'W C E
M�TERY ANO CREMATORI
�L�f7�3CpR ROAD Q(j"NSBURY UM
(518) 745.4g76 NEW YORK 128p4
(518) 745'•4477
Funeral Director
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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 remains of:
(Name) (Sax)
r,t i2-4
(Street) (city (Slate) (Bp Cade)
who died on o7�� day of 1/.4+'/LJ�i�T_200-1
Pp-fz L Fncs r At(s
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
to iHb rah �o 5 Z.
(Name) (Address)
Relationship to the deceased
Name of Funeral Home ~�i 1 C So'h. rah Q R uY� _M we
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
the
I r car*that I have full power and personal
authorization to have for
he cremation of the remains and to direct the disposition�removed may be destroyed,and agree to protect,fdefend and
cremated remains,that any persona possessions
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
groundless,false or fraudulent.
(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:
It 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
VL YJ L. VJ .1 C1 VV 111..14,
WAaxwGTC)N COUNTY
Washington County CARES .
Office for Aging and Disabilities Resources
383 Broadway
Fort Edward, New York 12839-2664
TELEPHONE: (518)746-2420
FAX- (818)748-2418 or 746-2571
Claire M Murphy,MSW
Executive Director
January 30, 2009
Jay Jillson, Owner
Jillson's Funeral Horne, Inc.
46 Williams Street
Whitehall,ICY 12887
Dear Mr. Jillson,
Upon receipt of this letter,you are authorized to cremate Fred Safl-a pursuant to the wishes of his
Guardian,Tanury Delorrne, Washington County Conunissioner of Social Services.
T anl:�-yo
Clair hy, Director
hingto County CARES
Agent for the C"oniniissioner
4L'eshington County CARES+S a collaporation between the Washington County Department of Social Services and the Office for'the Aging,supporting
the mission of service and protection of the flail and vulnerable in ftshington County