Allen, Suzanne rm
OF
QUEEVBUW01
PAVEDER' CEMETE
CEMETERY'
AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name VZ«
rn Case # ?
Date of Cremation I
Time Cremation Started
Time Cremation Completed to , q
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Type of Container -
Remarks :
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Town of Queerfsbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518) 745-4.476, Crematorium: (518)745-4477
The Authorization to Cremate
CrOMate the�rkensquests and authorizes Pine View Crartmfonium,In accader"with
and subject to Its Rules and Regulations to
S� ANMk, A //ems
� cAdOW W&f jA/�L—
(City) (state) Code)(ZiP
who died on � f�/
-- day of ' O vt�`t l�
at
( ) (Address) _0
eand address o/7-1 Oft relative or new of person aufl aamation:
AnIA4 eivLiAw�
(Name) �� /crQ a- '�Y/eadQcc) /�( �c-��o� L/b �t✓ N� /�d-�
( )
ReleftWip to the deceased
Name of Funeral Rome
IMPORTANT:
I represent that tom of my knowledge.the deceased(has)or(has no)pacemaker,dam,
cell,radioactive radioactive devioe in his or her body.(Ckde One) b�arY.battery pack,power
I certify that I have full power and
cremated remains.that �to arrange for the
cxemation of the remains and to direct the of save harmless Pine ViewCr �nal�ardall dairy and eOw been demands loved Y toyed'and disposition WOM defend and
by of or the cremation off remains as directed, far ices a damages which may be made against them/ wtnettner such claims or demands are or are not wholly
(Witness ' "Y
( and Address of Relative or Legal Repre)
Signed on this data:— R,41% , 9
Disposition of Cremated Remains
I hereby direct Pine View Qgmatodum to dispose of the cremated remains as fellows:
Mai to
r
� r
odw arrangernenls-Please specify:
If ptlrerbstion of Cremated remains is requested,chack here
Rwrieion:January 1.2W9
policies,Rules and Regulations
from 7:00am to 3:30pm. Prior telephone
Pine Viev�+Crematorium is located on the grounds of Pine��Cemetery. he
1. h Friday prearrangements,are
crematorium operates Monday throng p�Rang
arrangements for the aooeptan�of remains are necessary
me or Saturday cremations.
necessary for overti
nearest ne)dkin stating
2. A •Authorization to Cremate"form signed by thefor cremation of the remains
that they do have the power and authority personal possessions
and to direct the disposition of the cremated remains,that any ed,defend and save
have either been removed or may be destroyed and agree to prof
harmless Pine View Cemetery and Crematorium fromby d claims masonnnected and demands
for loss of damages which may be made agate Of said remains as directed,whether
the cremation of said remains and/or untildisp s
such claims are,or are not wholly groundless,false or fraudulent.This authorization in
s n the remains.
addition to a regular burial permit must accompany
d containers
3. All remains must be in a casket or suitable alternate Mastic cntainer-ontainers anbe aCCept -
must be of a combustible material. No styrofoa P
battery, battery pack, Per cell, radioactive
4. Any cardiac pacemakers,defibrillators, before any remains will be
implant or radioactive device must be removed from the body
accepted.
completed within three working days(72 hours)of receipt of the
5. Cremations will be comp
Burial Transmit Permit and Authorization to Cre te oys Of �cremated funeralnhome
be mailed via Registered U.S. Mail within three are made.There will be a�•00 charge
handling the service unless other arrangements
for this service.
6. Cremation,Administration Costs and Rem Fees:
Adult
-00
Children (age 13 months to 12 years) $2000.00
Infants (stilibom to 12 months) �.�
Overtime Cremations(W $5
Saturday Cremations