Loading...
Cembrola, Michael F. jotVl,b U GCC"2J Ztfr ' rINE VIEW CC%ICTERY Ind CREMATORIUM QUAKER RuAD, QUEE NS©URY, NEW YORK 12801 (519) 798 472'= (518) 793-9777 n n Funeral Dirictor Case No. � n��iC. Dale o-E Cremation Time Cremation Started � r 'rime Cremation Completed � T - •1?T'P of Container �� ', / T'.cm.�r.ks ..- _1 - �l yq'i i DISPOSI`PION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangement - please specify: If pulverization of cremated remains is requested, check here 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 :W ; TOWN OF QUEENSBURY PINE VIEW CEMETERY ^` J do CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777 AUTHORIZATION TO CREMATE 'I he undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: Michael Ferdinand Cembrola Name Sex RR 10 Box 97A Hampton, Xew York Street T City State Zip Code who died on 27 day of February 1990 at maple Terrace Community Care Home 143 Maple St.,Rutland Vermont Place Address —— Name and address of nearest living relative or name of person authorizing cremation: Marie C. Mercurio, RR 1 , Box 97A Hampton, New York 12837 Name ss Addre Relationship to the deceased Niece Name of the funeral home Douglas V. ring, Durfee Funeral Nome IMPORTANT: I represent that to the best of my knowledge, the deceased has or��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. r_ W' Hess Signature of Relative or Legal Rep. 119 X. Main Street RR 1 , Box 97A Fair Haven, Vermont 05743 Hampton, ltew York 12837 Address Address Signed on this date