Fafian, Elicio it)"N W bMt"tjI40tly *-'3�1
MINE VItN CEMEtE"y
I
t"EMMUR I UM
Oual<er Road, oueehsbury, New York 12804
Phone+ (518) CrematoriuO 745-4477 or if no Answtr
Cemetery 145-4476
nUtNdalZntIuN to CnF-mntE
The undersigned request 's and Authorizes Pine View Crematorium, in
accordAnce with and subj§ct tii it4 nulot And Regulations to
cremate► the rO*Ains of !
Elicio Barredo Fafian Male
(Name) (Se►i) -----
Fort , Hullson Nursing Home Fort Edward , NY 12828
(Street ) (city) (State) ( Zip Code)
who died on 21st day Of September 19_96
at Fort Hudson Nursing Home , U . Broadway , Ft . Edward , NY
(PlAce) (Addr044)
Name and addr044 of hearfgt living rtlAtiv# or hAm* df person
Authbriting CreMAtibh!
Mrs Florence Flint 92 Pearl Street , Hudson Falls , NY 12839
(NA(ne) (Addre40
RplAtiohthip to the deteatwd friend
Name bf lUnerAl Nome Carleton Funeral Home Inc .
IMP
represent a� to the bt+tt of try Nnowledgt, the deceased has or
�
hA4 nb path, ih hi § bh htr bbdy: (circle dn4)
1 tbrtify that 1 hAQE thb full poweth and authorization to arrange
for the cromaltion of the remAin4 And to direct the disp04itivn of
the± ct-obatod h-kMAihst that ahy 061-4"A1 pb4y644ions have+ either
beeh ,-#oov*d b.r may bt dp§tt^by§dt and agree to protect , defet'd
and §ave harmless Pine VieW CrOlhAtorium from any And All claims
and domands for loss or dA*dgti which may be mad# Against them by
roikeon of or tohn6ctod with th! _thtm&tion of Said remains As
dire , whether such t19144 br dfmAnd4 Arl! or Are not wholly
gr ndle s, a p or fraUdUltntc
GZ Carleton Funeral Home , Inc .
(Witnpss> (Addre9s)
Hudson Falls , NY 12839
(Signature%f Relative Or LtgAI Rep. And Addre+is)
Signed on thit
b i SPOS i t 1 UN OF Ct2EMn mt) nrlmm ms
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify :
If pulverization of cremate remains is requested, check here
POLICIES, f1ULr-S nNt) PEGULn r I UNS
1 . The crematorium will be open for crpmations 5 days a
7 :00 A. M. - 3:30 P. M. Monday-Friday. No Holidays or, Sunday ,
arrangements can be made for Saturday. Prearrangements I,,
telephone For acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pino
View Cemeteryi Quaker Obadi town of Oupensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do hs :�
the power and authority to arrange for the cremation of Fhf'
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 prbtectj defend and save harmless Pillp
View Crematorium From any and all claims and demands for loss nf
damages which may be made against them by reason of or cntlnectvd
with the cremation of said remains and/or disposition of satrl
remains As directed, whether such claims or demands are, or, .ar-�
not wholly groundlesso false or fraudulent. This authorizat- i
in addition to a regular burial permit most accompany thf?
remains.
4. All remains mutt be encased in a casket or Suitable alternate
Container. Caskets and containers must be of combustible
Arterial . No styrafoam or plastic containers will be accepted.
S. Th# question relative of cardiac pacemakers must be 111
on tho authorization to cremate form before the remains will t,r
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 120. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult W 5. 00
Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillbor-n
to 12 months ) t60. 00