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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,
cremate the remains of In accordance with aril subject to its Rules and Regulations to
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(Name) ,r> C Y Y� ( m r i � �c
,! Q ri i• ��n 1 rS cJ S�-
(Street) (COY) (State) (Zip Code)
who died on �
20_0L.!�j
at �gYY7
(Place) (address)
Flame and address of nearest living relative or name of person a ulttorizing cremation:
�i r�y,c. � �577 PY7T
(Name) (address)
Relationship to the deceased
Name of Funeral Home_. —'�.-
IMPORTANT:
I represent
tradioactive that
the best of my Ivwwledge,the deceased(has)or(has no)Pacemaker,defibrillator,battery,battery Pack,Doer
plant or radioactive device in his or her body.(Circle One)
I certify that I have fun power and authorization to array far 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 wNch may be made ffist them
by reason of Waded with the cremation of said remains as directed,whether such claimsdemands are or are r�wholly
ground se or fraudu
iajJ �1
� ) (Address)
Signature and Address o e L epresentative)
Signed on this date: c1 2 z c5 q
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mai to
Oam arrangements-Please spa*:
fE p►*Awtltion of cremated remains is requested,check here
Favbiom April 18,2007
Policies, Rules and Regulations
torium is located on the grounds of Pine
3 0pm. Prior telephone
1 pine View Crema through Friday from 7.00
crematorium Of.,
Monday prearrangements are
arrangements for the acceptance of remains are necessary.
necessary for overtime or Saturday cremations. stating
A "Authorization to Cremate"•form signed by the nearest next of kin is necessary
2 possessions
at the do have the power and authority to arrnlae9afthat any per the asonal fton f the remams
that Y
and to direct the disposition r the cbreedes�yed and agree to protect, defrrnd and save
have either been removed or and Crematorium from any and all claims and demands
harmless Pine View Cemetery reason of or connected with
for loss of damages which may be made against them by is authorization in
the
cremation of said remains andlor disposition of t°aid remains as directed,whether
such claims are, or are not wholly groundless,fse or fraudu the remailns.t.T
addition to a regular burial permit must accompany
ntainers
ner
ts
co
3. Or All remains must be in a casket or suitable alternate to cost i contaaske will nd accepted
must be of a combustible material. No styro oan
4. An cardiac pacemakers,defibrillators, battery, battery pack, power cell, radioactive
Y
im lant or radioactive device must be removed from the body before any remains will e
P
accepted.
of receipt of the
5. Cremations will be completed within three working eaForm.The cremated d remains will
Burial Transmit Permit and Authorization to
be mailed via Registered U. S. Mail within three are madeeThe a wf crmation �ltbe a $30.00 charge
he funeral home
handling the service unless other arrangements
for this service.
6. Cremation, Administration Costs and Recording$350 OOFees..,
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