Langer, Marilyn r"O`I N OF" QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l/UrIu
Name c„r /Al 5 g; Case # 5ql
Date of Cremation 1 ��Q h,b t r I� 200q
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Time Cremation Started 1' Z() P�
Time Cremation Completed 5 . 2o PM
Type of Container �rC Lwur(� ownr L 7 SFmoo C
Remarks :
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1 FROM :L.P.LANGER FAX NO. :B15-566-8127 Dec. 16 2009 02:34PM P3
-. 24PM Durfee Funeral Home 80 265-4464 P.9
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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 accordance with and subject to its Rules and Regulations to
cremate the remains of:
MARILYN ADAIR LANGER FEMALE
(Name) (Sex)
STAGE ROAD, BENSON VERMONT 05731
(Street) (City) (State) (Zip Code)
whodiedon FOUND: 15th day of DECEMBER 20 09
at HER RESIDENCE: STAGE ROAD, BENSON, VERMONT 05731
(Place) (Address)
Name and address of nearest living relative or name of person authors ft cremation:
MR. LAURENCE LANGER, 1513 NORTH ROUTE 23, MARENGO, ILLINOIS 60152
(Name) (Address)
Relationship to the deceased BROTHER
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator.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 claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed.whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: DECEMBER 16, 2009
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Otherarrangements-Please spa*: DURFEE FUNERAL HOME WILL RETURN FOR CREMATED REMAINS
If pulverization of cremated remains is requested,check here XXXXXX
Revision:January 1,2009
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
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 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 Cemetery and Crematorium from any and all claims and demanus
for loss of damages which may be made against them by reason of or connected w:Lh
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 contai;-;!-s
must be of a combustible material. No styrofoam or plastic containers will be
4. Any cardiac pacemakers, defibrillators, battery, battery pack, power cell, rad;K)Ectiv:
implant or radioactive device must be removed from the body before any 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
be mailed via Registered U. S. Mail within three days of cremation to the funeral hors
handling the service unless other arrangements are made. There will be a $20.00 c :. -ge
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) $150.00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations $550.00