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(518) 745•4476 (518) 745.,4-477
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 audxwizes pkw Vlew Crematorium,in accordance with and subject to its Rules and
cremate the remains of
Regulations to
L.
(Name)
(Sex)
{Street)
who died on {City}
(State) (Zip Code)
(S��y day of____at /.-�
. a4 _204
(Place)
' (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(�-1-A/4-I L. ;6nayJ ( PD —
(Name) (Address)
Relationship to the deed 0-
Name of Funeral Home_.,
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or s rto rxmaker,defibrillator or any other battery operated
device in his or her body. (Cbcie One)
I certify that I have fait{power and auitlwkatim to arrange forr the aernation of the
cremated remakrs, possession have either been tarnarxs and to diced the disposition of the
save harmless.t rig from any and an ith claims and Or
sy arbe m ,and defend mid
by rea or with the cremation of said remains as directed,whether such whxde y be�aga them
y
9�fa r hauduler-t claims or demands are or are not wholly
(Witness}
(Address)
(Silitnal re and Address Address of Retatrve or t.egat Representai'rve)
Signed on this date:
Disposition of Cremated Remains
1 hereby direct Aire View Crematorium to dispose of the cremated remains as folkms:
Mail to
Other arrangements-Plazas specify: fr4l W(a, /fir Cry U P
if pulverization of cremated remains is retied,check here _
Revision.January 1,20106
y
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary.Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"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 Piste 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 casUidt or s iftable aitemale container.Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers,defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations wiR be complc4W 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.
G. Cremation,Administration:Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12.months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00