Welch, Justine - �c n 1
P LN E Y7 E W C E �„r/ W B C�L
f�U.K�R ROAp,M TERM ANrp CREMATORI
QtlE�Ng9URY, KEw UM
(518) 745.4-076 YORK 128Q4
(S18) 745•gg77
F1vnerel Director__��{��, I ,
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Town of Queenstx,ry
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofiice:(518)745.4476,Crematorium:(518)7454477
Authorization to Cremate
The un*sV$ed requests and auihcr Pine View Oameto ium,in accordance with and subject to as Rules and Regulations to
crer`nwee the remains d: r ,: Fe-Al(Name)
ia£r -3
(may) (State) (LP Dods)
who died on ' � �y a �Ze,�
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at AaZ I iACZ Ct'Y1tU.AA W S t f rlf f�A2 IL sA.� r�
"NO) (Address) - / C-'VV4 j;P cC A I4(11.
Name and address of nearest ftV reiatim or name of person ahsltrorizkg cnsrneuon:
Oe&aj*-H Moc�
( arMne) (Address)
to the deceased
Name cf FwWM Dome Gc`WArd L. r K211 U (-tlhl F p I b^�o++r e_
IMPORTANT:
I rePrssant that to the beat of my knowiadge,the deceased(has)or(has no)pacemaker,deter ,beery,battery Pe
cei,radioactive krhpient or redtoactbe device in his or her body.(Circe One) &.power
amI certify that 1 have ft i power and ahtdWzWm tit arrange for the cremation of the remains and to direct the dispositlon of the
� Crematorium from
any and
eitherlms been removed or maybe dOy�.e4 to��defend and
any and d dims and demands for kiss or damages which may be made against them
by reason of or connected d with the txarrretiorh of acid remaths as dkacted,whether such calms or demands are or are not wholly
grorrndleas,false ar iraudulernt
(Address .
Uj(SWOtur )a;�: �a f Relative or L agc Representative)
Signed on this doW_ 3 y3 t/J1cc
Disposition of Cremated Remains
i harsby dha Pine View Cremewurn to dispose of tha crarnatad remains as toicws:
Mello
Olfher arrangerrhens-Pksese seedy:
If pwverization of cremated remains is requested.check two
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Rerisiom Apra 18,2007
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Policies,Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.
a P Thelephone
crematorium operates Monday through Friday from 7:O0a are
arrangements for the acceptance of remains are necessary.prearrangements,
necessary for overtime or Saturday ns<
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 arry personal possessions
agree protect,defend and save
have either been removed or may be destroyed
and 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,%Ise or remains This audwrizatim in
addition to a regular burial permit must accompany
the 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 change
for this service. .
6. Cremation,Administration Costs and Recording Fees: .
Adult $330.00.
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