Vairetta, Angeline .4� OF Q-UEE—?-AISB
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QUAKER ROAD, l-L �/'
VIER' CEMETERY- A� .lJ
CREMATORIUM
QUE'ENSBURy, NEW yORK 12804
(518) 745-4476 (518) 745-4.477
Funeral Director
Name
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Case #
Date of Cremation r
Time Cremation Started
Time Cremation Completed
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Type of Container
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Remarks ; 1e5 S�
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Town of Queensbury
Pine vew Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518)7454476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authortws Pkre View Cre
cxemate the remains of: matorium,In accordance withand subject to its Rules and Regulations to
(ram) (sex)
(City) (State) (Zip Code)
who died on 7 day of /1/JG` � 20 �G
at
—�fl
(Place) (Address)
Name and address of nearest living relative or name of person a
cremation:
(Name)
Relationship to the deceased /j/,��y
Name of Funeral Home C/
ce
IMPORTANT:
I represent that to the hest of my Ivrowledge,the deceased(has)or(has no)pacemaker defibrillator,battery,battery pack,per
ced,radioactive implant or radioactive device in his or her body.(Circle One)
creI oertUy that I have fud power and authorization to Grange for the cremation of the remains and to direct the disposition of the
mated remains,that any personal possessions have either been removed or
save harmless Pine View Crematorium from any and all claims and demands for loss or da be r ,and agree to erect,defend and
groundless,false by reason Of Or connected with the cremation of said remains as directed,y such claims or demands are or abe fire note against them
Al, V7
t,L
( ignature and Address of Relative or egal Representative)
Signed an this date: �lt�:l<-!� / "7, v2,4 d
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mad to
Other arrar►gemerrls-Please specify:
0 pulverization d cremated remains is requested,check here
RWision;Apt 18,2007
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of
00amne View
to 3:30pm. Prior telephone
crematorium operates Monday through Friday Prearrangements are
nce of
overtime
for
the or Saturday pe remains necessary.
ations.
necessary for
stating
2. A •Aurization to Cremate'form signed boya�e nearest
for thecremation of of kin is �the remains
that they do have the power and authority
and to direct the disposition of the cremated remains,that any peaf�e
have either been removed or may be destroyed
�m army an alalall claims and demands
harmless Pine View Cemetery and C of or connected with
for loss of damages which may be made againstthem by reason
dion of said remains as directed,whether
the cremation of said remains and/or false or fraudulent.This author in
I such claims are, or are not wholly 9 n the remains.
addition to a regular burial permit must accompa y
kets and containers
3. Ail remains must be in a casket or suitable aim ��containers will be a opted.
must be of a combustible material. No styro P
4. Any cardiac pacemakers,defibrillators,battery,
battery pack, power cell, radioactive
implant
radMctve device must be removed from the body before any remains will be
accepted.
will be completed within three working days(72 hours)of receipt of the
5. Cremations M to Cremate Form.The cremated remains will
Burial Transmit Permit and Authoriza*be mailed via Registered U.S. Mail withi of p'etrtation�the fiur>eral homen three days There will be a$30.00 charge
handling the service unless other arrangement
arefor this service.
6. Cremation,Administration Costs and Recording Fees:
Adult
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00