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PINE PINE REMATORIUM, INC.
Quaker Road, Glens Falls, NY 12801 I �
CREMATORIUM,INC. Phone (518) 798-4726 or if no answer 792-1114
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine Crematorium,Inc. in accordance with and subject to its Rules and
Regulations to cremate the remains of:
Mildred F. Raynor
(NAME) (SEX)
May Day Home, Box 214, RFD # 1 Poultney, Vt. 05764
(STREET) (CITY) (STATE) (ZIP CODE)
who died on5th day of May 19 R$—.
at Rutland ReFdonal Medical Center, Rutland, Vt. 05701
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Harland W. Cashmann, 7 Barnum Ave., Plainview, N.K. 11803
(NAME) (ADDRESS)
Relationship to the deceased Son
Name of funeral home Mallory Funeral Home, 4 South Park Pl., Fair Haven, Vt, 05743
IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no 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 Crematorium, Inc. 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
dire0qd, whether such claims or demands are, or are not, wholly dl ss, false or fra dulen .
(WITNESS) (SIGNATURE OF RELATIVE OR LEGAL REP.)
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(ADDRESS) X)'T Q'V003 (ADDRESS)
Signed on this date S & —IFF
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows:
Mail to Harland W. Cashmann, 7 Barnum Ave., Plainview, N.Y. 11803
Other arrangements - please specify:
If pulverization of cremated remains is requested, check here:
POLICIES, RULES AND REGULATIONS i
1. The crematorium will be open for cremations 365 days a year, 24 hours a day. Prearrangements by telephone for
acceptance of remains is necessary.
2. Pine Crematorium, Inc. is located on the grounds of the Regan & Denny Funeral Service, Inc., Quaker Rd., Town of
Queensbury - adjacent to Pine View Cemetery,Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next of 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 Crematorium, Inc., 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 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.
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.
PRICES EFFECTIVE MAY 1, 1986
Cremation, Administration Costs and Recording Fee:
Adult ............. ... ...... ... ....... ........... ..... ............ .... ........... $125.00
Children(age 13 months to 12 years) ......... ........... .... ... ............. ....... 80.00
Infants(stillborn to 12 months) .......... ................ ........................... 45.00
Shipping container, carton and packing fee for shipping and registered priority mail with return receipt included in the above prices.
ADDITIONAL SERVICE
Storage of cremated remains- per month ............ ............ .................... $ 2.00
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STATE or vEl"T
ZXAXWU'i PERMIT TO CARUATE A WAD NUUN SAD'
Mildred F. Raynor I . poultneyq Vt. 05764
e -ma ,Day Home. Box 214 RFD
P1400 4001A
Rutland But Reg,. Medical Center
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