Chabbott, Grace Iro`14N of QUEEN,5BU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �13 61A PC
Name CrCcc C1 1, , Case # .3U�
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Date of Cremation iU nn2y(y�
Time Cremation Started
Time Cremation Completed 4
Type of Container (cw(Lei(I r C&r;
Remarks :
3° 1
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (618)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and autltorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains at
9A C,!5:' tj . 614A /38o— T(Sex)
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(street) f� (may) ( ) (Zip Cam)
who died on day of _ J yT 20,E
at 2-2 -E LA T/,aV -17 LA F Pew►&P /v /
(Place) �' (Address) ,
Name and address of nearest living relative or name of person authorizing cremation:
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(fie) (Address) /�U JA/3LL /=012 iu
Relationship to the deceased PA l l as;C� `
Name of Funeral Home �l 13 G-[,4!L/C 1we Z 3l O �!'il i2.4ti.4 .4v F
IMPORTANT:
I represent that to the best of my laxwAecfge,the deceased(has) (het no oemalcer,delibfttor,battery,battery pack,mower
cell,radioactive hnplo t or radioactive device In his or her body.(
I certify that I have full power and euUwrb ation 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 dam and demands for loss or damages which may be made against them
by reason of or contacted with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,Pipe or fraudulent. .
2 3j o AyF
(W ) (Address)
ignature and Address of Relative or Legal Representative) J ti iLJ/z
signed on this dace: -J y- _ y 2 C70
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to M )3 C-LA&/e-
Z 3 4 v g�-y L,,4/6 L/-"l-A Ci 0 N1 JL'�y 6
Other arrangements-Please specify
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
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 theca 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 fraudulerrt.This authorbmtion 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,defibri lators,battery, battery ice►Per 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 fund 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 $330.00
Children (age 13 months to 12 years) $180.00
Infants (stilibom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00