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V'E`FV CEMETERY AND
QUAKER ROAD, CREMATORIUM
QUEENSBUR1l, NEW Y.ORK 12844
(518) 745-4476 (518) 745-4477
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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 acx:ordarnoe with and subject to its Rules and Regulations to
cremate the remains of:
HOWARD S. T)ARY,,_ SR. MATE
(Name) (sex)
82 HURLEY AVE. , LAKE PLACID, NY 12946
(Street) (City) (State) (Zip Code)
who died on 14 t h day of NOV.
at ADRK MEDICAL CENTER, SARANAC LAKE, NY
(Place) (Address)
Name and address;of nearest living net m or name of person authorizing a mom: -
SARAH BOND 360 RIVER ROAD, EPSOM, NH 03234
(Name) (Address)
Relationship to the deceased_ DAUGHTER
Name of Funeral Home M A Cl-A-", INC , I,AK E 121 AG1P, NY
IMPORTANT:
1 represent that to the best of my Imowledge.the deceased(has)or(has no)pacemaker.de9brftlamr,battery.battery pack,power
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 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 daims and demands for loss or damages which may be made agalrm them
by reason of or connected with the cremation of said remains as directed,whether such claims or derrends are or are not wholly
groun; flplge or fraudulent.
//! tea,4L 2310 SARANAC AVE. , LAKE PLACID, NY 12946
(A )
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360 RIVER RnAD, FPSOM, N 03234
(Signaune Address of Relative or Legal Representative)
5lgrtad on this date• NOV. 14, 2009
Disposition of Cremated Remains
I hereby direct Pine Vi Cre to dispospof the cremated remains as follows:
msut�oM. B. CLAR INC. 31 ACID, NY 12946
Other enrangements-Please spac8y: c'vLA ✓U•` �v///tic/C (,/1
ff pul�ion of cxerneted remains is requested,check there xx
Revision:January 1,2009
Policies, Rules and Regulations
1. Pine View Crematorium isnoca thou h Fr on the iday from 7:OOam to 3:30pm. Prior telephone
rounds of Pine View Cemetery.The
crematorium operates Monday 9 Prearrangements are
arrangements for the acceptance of remains are necessary g
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 crematon of the remons
ains
and to direct the disposition of the cremated remains,that any personalposse
ssihave 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) $1 50•00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations $550.00