Jackson, Arthur W sown U uee` J GGr
I'INE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSOURY, NEW YORK 12801
(518) 798 4 726
(518) 793-9777
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TOWN OF QUEENSBURY *)//y
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Arthur W Jackson ,yisle
(Name) (Sex)
7 Oneida Ave . , LaKe Placid. 1NY 4914-
(Street) (City) (State) (Zip Code)
who died on 28th day of Dec . 19 91
at AdrK Med . Utr . Saranac Lake , NI
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Elizabeth M. Jackson 7 Oneida Ave . . Lake Placid.
(Name) (Address)
Relationship to the deceased Wire
•
Name of the funeral home M. B . Clark, inc .
IMPORTANT:
I represent that to the best of my knowledge, the deceased has oi pacemaker in his
or her body. (CIRCLE ONE)
I certify that I have the 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.
ic -- 1 . Dc4 01-,
( tness) ignature of Rela a or Legal Rep.)
7 Saranac Ave 7 Oneida Ave . ,Lake Placid
(Address) Lake Placid (Address)
Signed on this date Dec . 29, 1991
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to ja- �Itix, girt.
27 Saranac Ave.
Lake Placid, N.Y. 12946
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here X
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday.
No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone
for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker
Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next to kin or other authorized
person 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 Crematorium from any and all claims and demands for loss of damages which may
he 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 or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to a regular burial permit must
accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
6. Unless other arrangements are made, the cremated remains will be mailed via Registered
U.S. Mail within three days of cremation to the funeral home handling the service. There
will be a $10.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
Adult $140.00
Children (age 13 months to 12 years) $90.00
Infants (stillborn to 12 months) $50.00
ADDITIONAL SERVICE
Storage of cremated remains - per month $2.00