Geanta, Stephanie 171-I qtiN OF.. QUEEN5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (0)("Jtr
Name S e �c,�� tp�;^ ti Case # (�
Date of Cremation SC l Z
Time Cremation Started % lU p
Time Cremation Completed 3 2 S
Type of Container �rc c4j o„urr 4 f Sr UW
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Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Offroe.518-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The undersigned requests and acahod me Pine View Crematoriaau,m aoowdance with and&A"ct to fts Rules and Regutadons to
cremate the ternaft or
Stephanie Geanta Female
(Name) (Sec)
200 Ski Bowl Rd, North Creek, NY
(stem) (0ty) (State) (Zp fie)
who died on 14th day of September Av 09
at Adirondack Tri-Co. Nursing and Rehab
(Place) (ems)
Name and address of nearest uvaeg relative or narne of person aumoruog crew ation:
(Name) ( )
Reiationship to the deceased 51 S rL---
Name otf-UMBiHome Alexander-Baker Funeral Home
IMPORTANT:
1 represent that to the hest of my knowledge—the deceased(has)or(has no)pacwwkres,deftiffliatV or any other battery operated
device in his or her body. (Cade One)
I certify that I have U1 power and auf#rorbsbon to and for the cxernsaim of the rester and to direct the disposMi of the
cremated rem�s,that y-�erS6rte"-T—'lessiors trsve effim been removed or ate►be dessb yed.wO agm to protect,defend and
save harmless raw Creme m any and aH debm and dry for toes or demagais►tAtich may be made against them
by reason tbnrtecDed wtitt aerrtaQarr at sad rernabs os drew,vkmghew sLich ci 1I s or derrsands are or are not wholly
g ,false or
(Address)
- . �C.
(Signariue aced Address of Relative or Legal Restive)
signeaonthiscrate: September 16, 2009
Disposition Ot Gremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
mail to
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remains is requested,awt ac Here X
Revision:Jyiy- 3t)04
1
Policies, Rules and Regis
1_ Pine View Crematorium is located on the groin of Pine View Cemetery. The
crematorium operates Monday through Friday f m 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 Cr+ernation's..gned by the nearest next of kin is teary stating
that they do have the power and au#wrky to arrange for the cremation of the remains
and to direct the disposition of Me 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 them by mason of or connected with
the cremation of said remains and/or disposition of said runs as directed,whether
such claims are, or are not vAXWY 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 s4molbam or plastic containers will be accepted.
4. Cardiac pacemakers,def'bsbrOlators of othm battery operated devices must be removed
before any remains will be asxepted_
5. Cremations will be completed with dwee vv*rMV day3(72}oum)of apt of the
Burial Transmit Permit and Authorbotion to Cie Fes-The cremated remains will
be mailed via Registered U.S. Mal vylthin three days of cremation to the funeral home
handling the service unless other arrangements are made.There will be a J215RW charge
for this service.
6. Cremation, Administration Costs and Recorckig Fees.
�j'
Adult $38B
Children (age 13 months to 12 years)
Infants (stillborn to 12 months)