Johnson, Ernest OF:.
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director All 1&,1c�—
Name UhnSu Case # QL
Date of Cremation 0C�11 . (- � Zook
Time Cremation Started_ Ic
aG, A h
Time Cremation Completed 1L) ' -to AM
Type of Container r � P(-I( _
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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 Office_518-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The undersigned requests and euttwrtws Pine.View Cmawtorium,m a000rrtr.,noe vAh and subject to its Rules and Regulations to
cremate the remains ot:
Ernest Johnson Male
(Name) (Sex)
323 Bartons Mines Rd. , North River, NY
(SUM) (CAY) (State) RIP Code)
who died on 1st day of October 09
at Adk. Tri-County Nursing and Rehab Center
(Place) (Address)
Name and address of nearest living relative or name of person at MmIzing cremanom
Alan Johnson D. Ocean Avenue, Apt. 15 , S . Portland, ME
(Name) (Address)
Relationship to the deceased Brother
Name ofFunemlHome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knaMedge,the deceased(has)or(has no)paceme1w.for any outer battery operated
devroe in his or her body- (Guile One)
I certify that I have fufi power and au torbatton to arrange for the cremation of the remains mid to direct the disposition of the
cremated remains,that any personad p stave eftm been rewa ed or may be desawled,and agree tD protect,da�end and
save harmless from any and alf and d for toss or which may be made agabW them
by or connected Bte cremattm ot`sala rerrre#rs as directed,yr *Aher such tAW -R ar demands are or are not wholly
g .false or
l�1Yd NS.
(W) (Address)
_C/r _ i-
'
X(Sii' rid Address of Relative or l egad R ttatim)
signed on tnrs sate: October 2, 2009
Disposition of Cremated ttemains
i hereby direct Pine View Crematorium to dispose of the cremated remains as tolfows:
Haan to
Other arrangements-Please specify: FH will pick up
If puivermabon of cremated remains is requested,cnecfc here X
Revision:4wy- 9D4
ibis/'= 0
Policies, Rules and Regulations
1. Pine View Crematorium is located on the gi<our►ds 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"Sighed by the nearest next of kin is necessary stating
that they do have the power and any to arrange for the cremation of the wins
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 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 adWKy groundless,false Or fratnMeM.This allfflOrtmOon 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 styrofoarn or plastic containers will be accepted.
4. Cardiac pacemakers,def'ibrillators or other banery operated devices must be removed
before any remains will be
accepted-
6. Cremations will be completed within three vMorking days(72 ham)of apt of the
Burial Transmit Permit and Aut orbmtiion to Qrerirate Form.The cremated remains will
be mailed via Registered U. S.Mai!wltti n days of cremation to the funeral home
handling the service unless other arrangements are Made.There will be a$�fir,00 charge
for this service.
6. Cremation, Administration Costs and Recording trees:
Adult $30&W -330
Children (age 13 months to 12 years) ,$159-
Infants (stillborn to 12 months)
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