Dodzian, Francisze V. jotill'b U UCei2J ! rV'
riNE VIEW CEMCTERY and CREMATORIUM
QUAKER ROAD. QU E NEW
YORK 12801
1 798 Q72G
(518) 79:3-9777
Funeral Dirictor
-� Case No. /d
t L�me UaLe of Cremation
'I'inM Cremation Started _
'Time Creakition completed
1 1 of Container r 1 �' t1d 4 'e oic 7'!
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DISPOSITION 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 Rueensbury.
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
fine 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
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TOWN OF QUEENSBURY
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
'fhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Francisze V. Dodzian Male
Name Sex
51 Rangely DR. Trumbull Ct 06611
Street City State Zip Code
who died on 26th May 90
day of 19
at Mary McClellan Hospital Cambridge, NY
Place) (Address) --
Name and address of nearest living relative or name of person authorizing cremation:
Gertrude (Barnosky) Dodzian 51 Rangely Dr. Trumbull Ct. 06611
Name Address
Relationship to the deceased Wife
Name of the funeral home M.B. Kilmer Funeral Home
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 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.
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4WR_�ess - �� �l ,
Signature of Relative or Legal ep. '
Address Address
Signed on this date