Montfort, Lois (-"'r"WN OF QUEEVBU9�y
PINE VIEW CEMETERi AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ay1..jo,�
Name Lis MbA-'t Case # Sul
Date of Cremation
Time Cremation Started 10 : 02 An
Time Cremation Completed
Type of Container
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Of ue- 518-745-4476,Crematorium:518-745-4477
Authorization to Cremate
The undersigned requests and autttort ms Pine View CreamUxutca,m a000rdsaoe with and sublact to its Rides and Regulations to
cremate the remains of
Lois A. Montfort Female
(Nam1664 S. Johnsburg Rd. , Johnsburg NY 12843
( ) (City) (State) Rip Code)
who died on 2 8 t h day at Dec. zu_�U
at her home (same as above)
(Place) (Address)
Name and address of nearest fivimg relative or nose of person at&t munng cremation:
William A. Montfort (same as above)
(Name) (Address)
Relationship to the deceased Spouse
Name otFuneratHome Alexander-Baker FH, Warrensburg_, NY
IMPORTANT:
I represent that to the hest of my tawwledge,the (has no)pacerrisker.deftd-JaW or any other battery operated
device in his or her body. (0wcie One)
I certify that 1 have tuft power tNtorizstiott to snangs for the crimmtio n of the rents and to dit ecx the disposition of the
cremated remains a tsaF �pow have Sher been removed or may be dea�oyed.and agree to protect,defend and
save View ore tm from any and ai) aril demands for toss a tuhtidh may be made aQairtst them
by or Contacted wMi me crematkm at sedd reirrri abs as drerled,vAm6w such dalms or denim are or are trot wholly
g false or Irsydt rtt
f ' Warrensburg, NY
(mess)
R `�-� .�.� Same as above
(Signature aril Relative or legal Rotative)
Signed on tnrs date: 12-3 0-0 9
Disposition or Gremated Hemains
I hereby direct Pine View Crematorium to dispose of the cremated remains as talows:
nail to
Other arrangements_Pose sPeqty: F H will pick up
If pulverization of cremated remains is requested.check here X
Revision:JyJ�7 3@l74
is,ifin, 07
Policies, Rules and Regus
1. Pine View Crematorium is gated On the gmu-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"skgried by the nearest next of kin is necessary stating
that they do have the power and authority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains,that any pal possessions
have either been removed or may be desmyed and age 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 remakes and/or disQosidon of said remains as directed,whether
such claims are, or are not wholly groundless,false or frateduleM.this au on 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. Cardiac pacemakers,defrbrOlators of oVm battery operated devices must be removed
before any remains will be aampted_
5. Cremations will be completed vviOiin three yorldng days(72 flours)of receipt of the
Burial Transmit Permit and Authwrization to Cremate Form-The cremated remains will
be mailed via Registered U. S. Ala7d within three days of cremation to the funeral home
handling the service unless other arrangements are mom.There wilt be a UR-00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $3�3- 330.
Children (age 13 months to 12 years) $ - i 90-
Infants (stillborn to 12 months)
$�0` i.3
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