VanBuren, Dennis Sr. jot,,//,b U
riNE VIEW CENIETERY and CREMATORIUM
QUAKER ROAD. Q EE 7[3�Y, NEW YORK 12801
(5I8) 79:3-9777 �
Funeral Dirictor
/� /T s� Case No.
UaLe of Cremation eJ
'I'inM Cremation Started
'Time Crenkition completed
1�E'e of Container
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DISP06i LION OF C REMATED REMAINS
I hereby direct Pine View Crematorium to dispos(: of tine cremated remains as follows:
Mail to p� A j"GP r� Pt„rn-A � to the Michael G. An iolillo
Funeral Home.
Other arrangement - please specify:
If pulverization of cremated remains is requested, check here . '
POLICIES, MULES 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, arrangement:, can be made fvr Saturday. Prearrangements by telephone
for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds, of the mine View Cemetery, Quaker
Road, Town of Queensbury.
3. An authorization for cremation properly signed by the ;,<,i,rusi €o kin or other authorized
person stating that they do have the power and aut►,,orit.y to arrange for the cremation of
the remains and to direct the disposition of the cremated remains, ti,a�. ally personal possessions
have either been removed or may be destroyed and agree to protect, &fend and save harmless
Pine View Crematorium from any and all claims and demands for loss of damages which may
be made against them by reason ai, or connecter with the cremation of said remains and/or
disposition of said remains as directed, whettrer such claims or de:u(ands are, or are noc wholly
groundless, false or fraudulent. This authorization in addition to a regular burial permit must
accompany the remains.
4. All remains must be encased irr a casket or suitable alternate Container. Ce.skets 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 ruade, 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 $ L, ��—� a�
Children (age 13 months t,) 12 years) $91r.0o
Infants (stillborn to 12 rg7onths) $50.00
ADDITIONAL SERVICE
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Storage of cremated remains - per month $2,0u
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_.. 1* MN OF t,lUt:1:NSBUILY
PINE VIEW CEMETERY ��
&
CREMATORIUM
Quaker Road, Rueensbury, 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:
Dennis James Van Buren, Sr. Male
Name Sex
Bull Frog Hollow Road Wells, Vt. 12887
(street)-- �City) —Ts — Zip Code
who died on 28th day of February 19 91
at Pine View Crematory, Queensbury, N.Y.
Place ��—(Adc ress
Name and address of nearest living relative or name of person autnorizing cremation:
Desiree Van Buren Bull Frog Hollow Road, Wells, Vt. 05774
Relationship to the deceased Wife
Name of the funeral home Michael G. Angiolillo Funeral Home
IMPORTANT: 210 Broadway, , Whitehall, N.Y, 12887
I represent that to the best of my knowledge, the deceased I;as or has no pacemaker in his
or her body. (CIRCLE ONE)
1 certify that I have the full power and authorization to arrange for the cremation of the
remains and to direct the dispo:ition 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 co;rnectefi with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
Hess aSrg;njitUA
.e r cive or Legal Rep.
2� Bull Froq_Hollow Road, Wells Vt
(Address) _—T-
;tlddress�
Signed on this date February, 28 , 1991