Golluscio, Catherine . /1iN OF QUEEVBUf�yPINE VIEWCEMETERY AN
D CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date of Cremation A� u5� 13 2
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Time Cremation Started
Time Cremation Completed IIoo A h
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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 and subject to its Rules and Regulations to
(Name)
(Sex)
(Street) (City) (State) (Zip Code)3
who died On ti{-h day of_A f 1f`f 1 S T ram___
at 48 ST• BERNARD STREET (ZARANAC LAKE NY
—
(Place) (AWE)
Name and address of nearest living relative or name of person
authorbft cremation:
f HART j G (`nT T rrSrTn 4$ ST RFR�rapD ST
(Name (Address) ._SARA iv H c iAKE, NY
Relationship to the deceased w i J S B AND
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my ivruwledge,the deceased(has)or(has no)pacemaker,deflbrillata,battery,battery pad*,power
cell,radioactive implant or radioactive device in his or her body.(Ckde One)
I certify that I have futi power and authorization to arrange for the cremation of the remains and to direct the disposition
cremated remains,that any personal Possessions have either been removed or may be destroyed,and of the
save harmless Pine View corium from any and an Claims and demands for koes or agree to Protect,defend and
by reason of or connected with the cremation of said remains as directed,whether such claim d are or are h may be rnade agalrw them
groundless false orf duierrt.
2310 A A V D, NY 12946
(Address)
�`�48 ST. BERNARD ST SARANAC LAKE, NY
i;9
and Addresss of Relative or Legal Representative)
Signed on this date: 7 r 3 — t
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
MON10 M_ R_ CT-ARK, TNr• -
231 0 SARANAC AVF , LAKE PT ACTnf NY 12_94F,
Other anrngaments-Please specify:
If pulrerboWn of cremated remake is requested,check here X
Revision:January 1,2W9
Policies, Rules and Regulations
1. Pine View Crematorium isndoc'a th ou h F 9day frdon+7:OOam't 3:30pmePrior telephone
crematorium operates Mo Y g Prearrangements are
arrangements for the acceptance of remains are necessary. 9
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 f the ions
ains
and to direct the disposition of the cremated remains,that any personalposs
ess
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 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 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 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.
6. Cremation,Administration Costs and Recording Fees: •`
Adult - $350•00
Children (age 13 months to 12 years) $200.00
Infants (stillborn to 12 months) $150.00
Overtime Cremations(WeekdOYs) $550.00
Saturday Cremations •00