Tunney, Doris OF QUEEVBU-rRy
PINE VIEW CEMETERY AND CREMATORIUM '
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director PS f
Name orS t
Case #
Date of Cremation �yr� r Z tU
Time Cremation Started
Time Cremation Completed W ZS ' Jn
Type of Container ���� � .
r C
Remarks :
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71
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518) 745-4476, Crematorium: (518) 745- 477
Authorization to Cremate
The � and author¢es Pin,View Crematorium,in accordance with and subject to Its Rules and Regulations to
(Name)
7
(�I
ou ,�� .O�e,d� �ta6v
(strew
Who died on
day of 0,6Ce y,6f,,Z at 20 C� y
%/SI,E �i.�lrs
Name and address of nearest livingrelative or name of per;,
y,9 AJ d � au "g«emation:
{Name) (Address)
Relationship to the domed ,QAu Off T£/?
Name of Funeral Home
IMPORTANT:
i MProsent VW to the best of my ID'howiedge,the deceased
Y-od
cell,radioactive imPW or radt Wive device in his or her body Or c no)Pacemaker,defrbriiletor,
� (Circle One) Wary,bWery Pam.power
I certify that I have f A power and augxxization toWangefor the cremation of the
cremated remains,that any personal possessions have edher been removed f t remains and to direct the disposition of the
by reason orof9 View Crematorium from any and all daims a connected with thend demands for loss or be dyedftnegas,andwhic agree to Protect,defend and
,a Imlew be made against#.m
of said RMIWns as directed,whWw such c cards are or are not wholly
(Witrhess) (Address) N /a" /
�- '36- � Z�/
y
( store ress of Relati r I Representative)
l �
Signed on this date:
Disposition of Cremated Remains
i hereby drteot Pine view Crematorium to dispose of the cremated remains as follows:
Mall tD
Other arrangements-Please spe lfyr
If Pukwm@k)n of cremated remains a requested,check here
Revision January 1,2009
Policies, Rules and Regulations on the rounds of Pine View Cem�eP ar The
1. Pine View Crematorium is located tthrough Friday from 7:00am t Prearrangements are
crematorium operates Monday
arrangements for the acceptance of mains are neoessarY•
for overtime or Saturday cremations•
necessary stating
ned by the nearest next of kin is necessary
2. A -Authorization to Cremate-nd authority to arrange for the cremation of the remains
that they do have the pow personal possessions
and to direct the disposition of the cremated remains,g ee t protect,defend and save
have either been removed or may be destroy
less Pine View Cemetery and Crematorium fro m any
Y and all
claims orr connected with
s
harm le be made against the y
for loss of damages which may disposition of said remains as directed,whether
the cremation of said remains an dlor
such claims are, or are not wholly groundless,false or fraudulent.This author�tion in
addition to a regular burial permit must aocompanY the remains.
d containers
All remains must be in a casket or suitable alternate�stic stainers will beaCCepted•
ner.Caskets
3. ofoa P
must be of a combustible material.No styr
defibrillators, battery, battery Pads, power cell, radioactive
4. Any cardiac pacemakers, before any remains will be
implant or radioactive device must be removed from the body
accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
he cremated remains will
Burial Transmit Permit and Authorization to Cremate a of«cremation
to the funeral home
be mailed via Registered U. S. Mali within threentts are made.There will be a$30.00 charge
handling the service unless other arrangements
for this service.
6. Cremation,Administration Costs and Recording Fees:,
Adult
-00
Children (age 13 months to 12 years) $100:00
Infants (stitibom to 12 months)
$550�
Overtime Cremations(W 00
Saturday Cremations