Brown, Charles J QU
m EPINE YiEW CE L�T�B
M�TrrRy A1YD CREMATORI
s��3CP� ROA D, QIIEENSBtlRY, UM
(S18) 745.4.476 ( NW PORK Iz8oa
518) 745"4.477
/ r .' n 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:
Chu.iles 9,
(Name) ��{ T (Sex)
Z 4 1 Cou Yf ct nd
(Street) pp (City) (S e) (Zip Cade)
who died on 'rn TEA day of N1 CL Cc'k 20 09
at e Co Lx-r+L-L ra1�1vd it�rZoi E �cY-lc .
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
r
-f-t=EN i✓ A 1�7-rs"A t j C.CVD('r
(Name) (Address)
3a7 7 I Relationship to the deceased S�S�—
f,�1
Name of Funeral Home I 1 D Tt I YYIPX 1i 1Pt�t�l� YYI�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,deflbrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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
groundless,false or fraudulent.
Wiliness) (Address)
�����r,rn���CD
(Signature and Address of Relative cr 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
Mar_ 25 2009 10: 43AM INMAN SHIPPING WORLDWIDE 900-356-0421 page I
2312�/2009 11: 18 385252771.1. PINELLUFL�'RALHM PAGE Cl
03f25f2809 08:26 3862!tilt@6: hEDICa�iL {A,NIiJER PAGk 0LiO1
Office of the McWcol ]Examiner
District 7 and 24
Cremation Authorization
Year. 2009 APprowel Number CRAWS Amtkurization.0sru T mo.- 3l25i2€ %9:t6,32 AM
Dumod:
Lan Hame $R( %IN Rimt No0w; CHARLES Middk ltra , 9.
Age: 44 luttr While set; M 006 9f prank., vi s"2009
stKa9t+{i Thyaiciva, GrsBN'y L.Ortep.lVf.D.
Fmwral home: fi:,l1ELLO Rt1'MAL HOME
Autborizeflea►Rtviewed Dr. Jessica Lunt
Crcmall9n Authtt�td by, Frvdmg Balie,M.D.
No Ira.. No