Haroff, Edward QU E
E 9\�5 B c...l 1
M �
� R ROAD, AtvD CREMATORIUM Q11E1?NS9l1RY KEW YORK 17804
(518) 745•4-476 (518) 745'•4-477
Funeral Director
vame
�•�
Cases+ �
n f Crematl.on
U
T.e : rematlon Started061
3V' : me Cremation Completg,d /2
Container
r
CIC
I
I
I
I
I
I
Town of QueensburY
Pine View Celnetery 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 suthorwas Pine View Crernatorkxn,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
C #�)n i-A (2 Ala hd
(Name) ® ( )
3 �W 1'e r not— City)'S cat Fes? N
(Street) (State) (LIP U006)
who died on Ill day Of 121—C'`� 20at
c?
(P1 ) (Address)
andeddressofnewas!-livft FOMOO-GF�°fP�ar`s`r11'°rizir'gaemedom__Jr- r _-qR Folder
( 1. 1 , (Address)
Relationship to the deceased w ^G�
Name of FunerM Horne�a' a%►
IMPORTANT: the deceased(has)or(has no)Pacerr+eker,defibrNlatar,battery,battery pack,Power
I represent that to the beat of my lanaaledge.
ceN,radioactive or radioactive device In his or her body.(Cirde One)
1 certify that 1 have full power and authorbadon b arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any POWMdpossessions have either been renamed or may be destroyed,and agree to protect,defend and
save harmless rune View Crenrreto m from any and all dial and demands for Ioss or damages which may be made agaiW them
by reason of or connected with the aeffm*m of said remains as directed,wtwow such claims or demands are or are not wholly
groundless,false or fraudulent. 6-/ 9 a o
(y1 ) (Address)
(Sig 11 pitui skid Address of Relative or Legal Representative)
Signed on this date.
Disposition of Cremated Remains
I hereby direct pine View Crematorium to dispose of the aemated remains as follows:
Mau to (uu„//` `I� -
Other arrangements-Please specify:
if pubreri scion of cremated remains is. ,check here
Revision:January 1,2009
i
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 - --- - - - -
a