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Deyette, Alexis Sr. TOWN OF QUEEVBU9?'Y- Nw PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director A I d Name Fl .XIS L ��y ITT �'r Case It J Date of Cremation Time Cremation Started Time Cremation Completed '0 �► f Type of Container © 141( CLSke.t— 3t--� C )qS'z- Thy Remarks : 1! �� � 1 o P m 1� II lI 11 i DISPOSITION OF CREMATED PY-00 INS I hereby direct Pine Vie" Cremetorlvm t: o dispose of the cremated remains as follows : Ma 1 1 t o _ -- ------- --------.-.-- ___- - --------- Other arrangements - pl- e,,e snfcr fy : -_-_-_ If pulverization of cremate remains is requested, check here -"""` POLICIES, RULES nND "EGULAT I ONS 1. The crematorium will be oren for cremations 3-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, Tn+an of Uueensbury. 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 dispositiot, 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 be made against them by reason of or connected with the cremation of said remains and/or disposition of said remains as directed, whether sj.�ch claims or demands are, or are not wholly groundless, false or fraudktlPnt . This authorization in addition to a regular huri.al 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 tt-ie cremated remains wi l l be mailed via RegistprPd U. S. Mail within three days of cremation to the funeral home handling the service. There will be a $20. 00 charge for this service. Cremation, Administration Costs and Recording Fee : Adult $ 175. 00 Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn to 12 months) $60. 00 p ss TOWN OF OUEENSBURY PINE VIEW CEMETERY R CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 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: Alexis Elmer Deyette Sr. Male (Name) (Sex) 8023 Myrtle Ave. Kingsbury, NY 12839 (Street ) (City) (State) (Zip Code) who died on 28th day of January 19 97 at Glens Falls Hospital 100 Park Street Glens Falls, NY :?Ani (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : Mrs. Bernice Deyette 8023 Myrtle Ave. (Name) (Address) Relationship to the deceased Wife Name of Funeral Home Carleton Funeral Home Inc. IMPORTANT: I represent that to the best of my knowledge, the deceased has or has io 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. 1 (Witness) (Address) —" (Signature of elative or Legal Rep. and Address) Signed on this date :