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Castro, Rafael L O TII'Irl V_J �`/1I// O F Qr7 B U-Tly �I• V PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director AA c/ --�)r,-tz moTir Casez a-e I�Ii& Y)C 1-- �' I!k `:���2C� Z. 1 .a : e Of Cremation — J �J Zd0 Cremation Started ' :-.e Cremation Completed • :e of Container CA&\2D ''30 14\mot/ � . arks �7 ()VkA 4� 3� +A . dqr' .,. C, a ro0-4 I> i FROM :FRA1-4<LIN CF IRC OFFICE FAX NO. :15184836040 4199 Jan. 12 2005 11:21AM P2 Ag%M Clayton Powell, Jr., Sladft OffICS Building 1 t13 West 125 Street lath Moor GLUM S.Q00ft New York, Now York 10027 FRANK A.MM *EY 21940-40 Wvry COW&M. comm=109" PERNOSION FOR STATE CREMATION PROC'mm vs Dear Recipient: This letter is to certify that L 644&9j�?-�F e9jj'w air)the (Name of Inmate's Relative) _S of who WU an 44 (Relatiorahip to Inmate) (Name of IaTrutel s Kin) inmate at the �rl Iq A Correctional Facility. (Name of the facility) The i=sae passed away on (Date of demise) ve the Now York State Depaitzent Of COrrectiOnal (Office of Mirdstezial &Fr gmily ServiooS)permission to cremate the remains and to skip p the remains to the fo=j ly at ttw fo,)110 WW add rC 35 JWP-1Z P M1 N..21n. This will be done at no cost to the family. (Jr Ship the remaits to die followWg funeral home Num.-- Address!_ Telephone N.UmWr.- r Family's Request Signature: Date'. Time: "j DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: 1 Mail to f{f ) ©/ Other arrangement - please pecify: If pulverization of cremate 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. Pre-arrangements 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 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 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 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 Styrofoam 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 $25.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $300.00 Children (age 13 months to 12 years) $150.00 Infants (stillborn to 12 months) $100.00 * Additional $100.00 charge for cremations done after 3:00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $100.00 Any remains received after 3:30 P.M. Mon-Fri or Saturday will be charged an additional $100.00. i TOWN OF QUEENSBURY PINE VIEW CEMETERY /L CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745-4477(if no answer) Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and sub' to its Rules and Regulations to cremate the remains of: • sect �.(NAME) '1�0 C/�- (STREET) ( - ��— ITY) (STAY � it CODE) who died on day of 4 h rJ4� 20&T--' 001 at (PLACE (ADDRESS) Name and address of nearest riving relative or name of person authotizin cremation: tion: oJC Relationship to deceased _ G Name of Funeral Home IMPORTANT I represent that to the best of my knowledge, the deceased as has no pace n his or her body. (CIRCLE ONE) I certify that I have the full power and authorization to arrange for the cremation of the remain to direct the disposition of the cremated remains, that any personal s and removed or may be destroyed; and agree to protect,defend and saveh armless P��r been ;6;rnatorium 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. (WITNESS) (AD SS) (SIGNATU ELATIV R L AL REP.AN ADDRESS)+ / Signed on this date: l / g