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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 remainsf.
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RY7Lc )r7c 1 C r' n
(Name) (Sex)//
(Street) (City) (State�Zip Code)
who died on L d Z2�i 15 day of 20_
at ,�
(Place) (Add )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased roc"c S c�
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or ha�no) malw,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Cie
1 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 connectedPeth the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless, se t.
(Address)
(Signature and Address of Relative �egal Represer ive)
Signed on this date: 2 7 h
Disposition of Cremated Remains
I hereby deed Pine View Crematorium to dispose of the cremated remains as follows:
Mai to
Other arrangements-PWw specify:
f pulverization of cremated remains is requested,check here
Revision:Ap6118.2007
i
Policies, Rules and Regulations
he
1. Pine View
Crematorium 's located on the grounds of Pine ViewCemetery.
rpm Prior telephone
crematorium operates Mondayhrof 9emains are necessary. Prearrangements are
arrangements for the acceptance
necessary for overtime or Saturday cremations.
2. A "Authorization to Cremate"form signed by
the nearest next of kin is necessary stating
ion
that they do have the power and authority to arrange remains,for the that any perstonat fpossess ons
the remains
and to direct the disposition of the cremated
have either been removed or may be destroyed
from aand ny and all c to laims and and demands
6nd and save
harmless Pine View Cemetery and Crematorium
for loss of damages which may be made a9a inst them by s as directed,whether
n of or connected with
the cremation of said remains and/or dispositon of laid remain
such claims are, or are not wholly groundless,
false
or remains.
fraudulent.This authorization in
addition to a regular burial permit must accompany Y
3. All remains must be in a casket or suitable alternat r past c containers willntainer. Caskets accepted
d containers
must be of a combustible material. N ty ofoam o
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 Lion to Cre'ng mateays Form.The cremated remains will
hours) of receipt of the
Burial Transmit Permit and Authorization
be mailed via Registered U. S. Mail within three days
madeeThere wmation �ltbe a $30.00 charge
handling the service unless otherarrangements
for this service.
6. Cremation, Administration Costs and Recording OOFees.J
Adult
Children (age 13 months to 12 years) $200.00
Infants (stillborn to 12 months) $150.00
Overtime Cremations(Weekdays) $550.00
550 00
Saturday Cremations