Gaynor, Sherry Qu rE���8 C
PINE ti'•(EW CE f7 �
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M�TERY AND CREMA
U7lKPR ROAD, TORIUM
Ql1EL'NS9URY
(S18) 745•4-476 �w YORK 128oa
(518) 745•4-477
FQneral Direc
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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 socordance with and subject to its Rules and Regulations to
cremate the remains of
SHERRY L. GAYNOR Female
(Name) (Sex)
_ 89 Greenwood St. , Lake Placid, NY 12946
(Street) (CRY) (State) (Zip Code)
who died on 3rd dayof April 20 09
at Adrk Medical Center, Saranac Lake, NY
(fie) (Address)
Name and address of nearest living r+ele*ve or name of person auWKxb ng cremation:
MichAEL Mosher PO Box 212 Vermontville, NY 12989
(Name) (Address) -
Relationship to the deceased Brother
Name of Funeral Home M B Clark, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,deflbrilAW,battery,battery per.POW
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 tisposkiort 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 frg(rt'any and ay claims and dmlrrrands for loss or damages which maybe 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, y��ud<mlent.
G 231Q Saranac Ave. Lake Placid,j NY 12946
(Witness) � Address)
44 --.)A'6-J-d <75� Greenwood St . , Lake Placid, NY 12946
(Sig and Aditw of ReWva or legal Representative)
Signed on this date. April 22 , 2008
Dispositiort of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mailto M B Clark, Inc.
2110 Saranac AvP a T,akp.Placirlp My 17946
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here XX
Revision:April 18,2007
l
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 gemated 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 ma0e 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 pacegakers,defibrillators, battery, battery Imo, 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 wod0ge 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 feral home
handling the service unless other arrangements are made.There will be a$30.00 charge
for this service.
6. Cremation,Administration Costs aniRecording Fees:
Adult $330.00
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00