Cole, Mary rNIN OF. O.0
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director LE N�c2
Name_ Mh�h �I �y
Case #
Date of Cremation ' vc�'
Time Cremation Started
Time Cremation Completed � ��
Type of Container �G1��
�rf� s� 0
Remarks :
_ iv
I
I
i
I
I
I
i
i
. i
I
I
i
I
4r
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 Pate View Ccerratonum.m a000rdance wt3h and subject to its Rules and Regulations to
cremate the remavts w-
Mary L. Cole Female
(Name) (Sex)
10 Manor Rd. , Apt 5s North Creek, NY 12853
(Street) (city) (state) (Ztp code)
who died on 29th dayof November 09
at Glens Falls Hospital , Glens Falls , NY
( ) (ems)
Name and address of nearest living refs Uve or name of person authorvx g crernattM
saO
(NaR1e) ( ) -'
Relationship to the deceased Cam-'S-(,4
Name ot Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my Wwmedge,the deceased(has)or(has no)pacemaker,deffbn1kaw or any otter ba tery operated
device in his or her body. (Ciede One)
1 certify that i have tub power and authorizaton to arrange for the crerorion of dw rer twins and to dttect the dWoshion of the
cremated remains,that any personal possessions hale ewer been removed or mW be desb lr®d,and agree W protect,defend and
save harmless Pine Vi matarium km any and all den and dam for toes or dwriages which rosy be made agabW them
by reason of o wtift the t se!d rerrtaiF+s as dretsad,tip such ded sardernm ate or are not vrattoiry
grotutd lse or .
(Witness) (Address)
CiRM C jVAIL
(Signature and Address of Relative or Legal RtepresenUlrve)
Signed on tins Gate: November 30 , 2009
Disposition of Cremated Hemalns
I hereby direct Pine View Crematorium to dispose of the cremated remains as tollows:
Mall to
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remains Is requested,cheat nere x
Revision:4wy- 29t74
Policies, Rules and Regulations
1_ Pine Year Crematorium is located an the gror-tis 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 Cry"s..gned by the rNmirest next at kin is wry stating
that they do have the porker and aulfiity to arrange fcw the cremation o€the wins
and to direct the disposition of Me creme wins, tat h arry Pal dons have either been removed or may be destr Dyed 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 remains and/or disposition of said remains as directed,whether
such claims are, or are not wholly groundless.1a*M Or fratxkde t This authortwtion 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 sum or Plastic Containers will be accepted.
4. Cardiac pacemakers,defibrifiators Of Other battery operated devices must be removed
before any retain will be accepted_
6. Cremations will be completed wiEhe three worldng days(72 hours)of rapt of the
Burial Transmit Permit and Author ion to Crime Form. The cremated remains will
be mailed via Registered u.S. Mail wlthea throe days of cremation to the funeral home
handling-the serve unless other arrangements are made.There will be a j rW e
for this service. fir$
6. Cremation, Administration Costs and Rig Fees:
Adult
Children (ageY13 monthsyears)to 12 C'r�
SISO.- 3 -
Infants (stillborn to 12 months) ) �� ��n�- .3J