Brown, Kenneth TIN OT. O.UEE-rA(SB Ujr
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW Y.ORK 12804
(518) 745-4476 (518) 745.4477
I, (� Funeral Director Ale��,,,Jvr
Name I�tn(wfL 1Jrow„
Case 5Z�
Date of Cremation 160
Time Cremation Started
1�
Time Cremation Complet�d M
Type of Container << ,,� o�yr
IV
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Roast,Queensbury. New York, 12804
Cemetery Office:518-745-4476.Crematorium:518-745-4477
Authorization to Cremate
The undersigned requests and autttorbms Fkw View Czemawri im.in aoowdance wAh and so Mac to its Rules and Regulations to
cremate the remains or
Kenneth Brown Male
(Name) (sex)
6 Ridge Ave. Warrensburg, NY 12885
(Street) (City) (State) (Mp Code)
who died on 9th day of December io 09
aL Glens Falls Hospital , Glens Falls , NY
(PISM) (Address)
Name and address of nearest living relative or name of person awwravV cremation:
(Name) ( )
Relationship to the deceased
Nameotf-uneral HomeAlexander-Baker Funeral Home
IMPORTANT:
t represent that to the hest of my knowledge,the deoeased(Eras)or Bias no) r or any other bmary operated
device in his or her body- (Circle One)
I certify that I have fuff power and auMorbotim to arrange for the cr+l#rratio n of the reffains and to direct the disposMon of the
cremated rema><ts,that any personal Possessions;how eMm leash removed or ma r be deseoged,and agree to poolem defend and
save harmless Pine View Crerrtatman Tram any and ati dedrits and demands for toss or dwneps wMch may be made against them
by reason of or Connected wlth the cremadan of saW rernrgrts as directed,whether such cialrrts or d are or are n�wiroilyy
groundless.false or trsudtaem
(NVmness) (Address)
(Signature and Address of Relative or Legal motive)
5lgnea on tuts Date: D P c P m h P r 10, 2009
Disposltron of Gremated Hemalns
I hereby direct Pine View Crematorium to dispose of the Cremated remains as follows:
Mall to
Other arrangements_Please amity_ F H will pick up
If pulverization of cremated remains is requested,cnedc here x
Revision:401- 9a4
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grou^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 Crerr "signed by the nearest next of kin is necessary stating
that they do have the power and audwdly to arrange for the cremation of the mains
and to direct the disposition of the cremated rematins, 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 demands
for loss of damages which may be made against them by reason of or connected with
the cremation of said remairis and/or d of said remains as directed,whether
such claims are, or are not wholly groundless,false or went.This au#xxization 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,defibMWOrs or otter baUery wed devices must be removed
before any terrains will be accepted-
S. Cremations will be completes#wi# m three working days(72 hot")of receipt of the
Burial Transmit Permit and Auftnization to Cremate Forth_The cremated remains will
be mailed via Registered U. S.Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made.There will be a$215RW charge
for this service. , L
6. Cremation, Administration Costs and Recording Fes:
Adult -33c;- _�;,
Children (age 13 months to 12 years) $158-W /;90- `3D
Infants (stillbom to 12 months) -"'
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