Brancati, Dennis pr1vE nEw uE .
CEME
TER AB �-1
Q �R ROAD, ANC CREMq
QUBPNsstrRy, NEW
(518) 745-4476 YORK 12804
(518) 745-4477
Name Funerel Dirt Q ecor 7
LtA z Urc.,c5 J I Iso„
Date of Cremation Case
Time Cremati � � l' ZO
on Started 2Up
Time Cremation �, SS b
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Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery pCe; (518) 745-4476, Crematorium: (518) 745-4477
The undersigned requests and auftrizes Authorization to Cremate
ate
crem the remains of.. Pine View Crematorium accordance,i
_ with and subject to its Rules and Regulations to
(Name)
(Sex)
(Street) (City)who died on l�j (State) (Zip Code)
_ day of ���W�fRn.r
at ZO�f
Place)
ace) (Address),
102
.�s r��s 7i1� .E
(Pl
Name and address of nearest living relative or name of
Person authorizing cremation:
(Name)
(Address)
Relationship to the deceased GU//�L�
Name of Funeral Horne
IMPORTANT:
I Power
represent red. loa 9194 imp best of my WwMedge,the deceased(has) (has no Plant or radioactive device in his or her body,(� grrefIlator,battery,fiery pa��
i certify that I have full power and au#xxt mtion to arrange
cremated remains,that any personal nge for the cremation of the remains and to direct the disposition
save harmless Pine Viewrom have either been removed or may Position of the
by reason of or connected wfF�um anyand all claims and demands for loss or 1OY��and agree to Protect,defend and
groundless,false or fraudulent. cremation of said remains as directed,whether claims
or which may
made againstwholly
them such claims or demands are or are not wholy
---------------
Oltness) (Address)
(Sign ure and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby died Pine View Cremebrlum to dispose of the cremated remains as follows:
VAI b
01w arrangements-Please specify: liJ 1,4e
M puiverization of cremated remains is requested,check here
t/
p ftbr.January 1.2M
Policies, Rules and Regulations
rounds of Pine View Cemetery.rnfor telephone
he
through Friday from 7:OOam to 3:30p ements are
1 Pine View Crematorium's nagted on the g re necessary-Prearrang
crematorium operates acceptance of remains a
arrangements for the accep cremations.
necessary for overtime or Saturday stating
remate"form signed by the nearest next of kin is necessary
A °Authorization to C and authority to arrange for the cremation of the essions
2 personal poss
that they do have the power agree to protect, defend and save
that any
and to direct the disposition of the cremated reedd and ag
n removed or may be destroy and all claims and demands
have either been and Crematorium from anyreason of or connectedether
harmless Pine View Cemetery be made against them by
for loss of damages which may ition of said remains as directed,
wholly roundless,false°r fraudulent.This authorization in
the cremation of o are remains
y g r undle an the remains.
such claims are, or
burial permit must accomp Y
addition to a regular
casket or suitable alternate container.ic containerswi11be containers
3. All remains must be in a rofoam or plant
must be of a combustible material. No sty battery pack, power cell, radioactive
4. Any cardiac pacemakers, defibrillators, battery, before any remains will be
P
im lant or radioactive device must be removed from the Y accepted.
da s 72 hours) of receipt of the
5. cremations will be completed within three working y ( The cremated remains will
S. Mail within three days of cremation to the funeral 00 charge
Burial Transmit Permit and Authorization to CremateForm.There be mailed via Registered ements are made.
handling the service unless other arrang
for this service.
and Recording Fees
g. Cremation, Administration Costs $350.00
Adult $200.00
Children (age 13 months to 12 years) $2 000
Infants (stillborn to 12 months) $550.00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations