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E VIEW CEMETERY AND CREMATORIUM
Q11'—F—R ROAD, QtJEFNSBURY, NEW YORK 12804
(518) 745.4.476 (518) 745'.4477
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518)745-4477
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:
Mrs. Viola Louise Miller _Female-_- -.
---- )Name) ------ (Sex)
25 Mechanic Street Fair Haven, Vermont 05743
- -- (Streeq^ --- - ---- - (City)
who ----------- - --(State) (Zip Code)
who died on 25th day of March _ 20 07
at Rutland Regional_Medi e cal Centr,160 Allen ST, utland,VT 05701
---(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mr. Gerard J. Miller,Jr. , 25 Mechanic Street,Fair Haven,Vt 05701
-- (Name) (Address)
HUSBAND
Relationship to the deceased
Name of Funeral Home DURFEE FUNERAL HOME.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have 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 crem • of said remains as directed,whether such claims or demands are or are not wholly
false or
ground n.� u I. ��--� ------- --------
--- - - -
(w• � r (Address).
(Signatur nd Address of Ref a or Legal Representative)
March 26,2007
Signed on this date: — -
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to -- --- - -'-
Durfee Funeral Home to return for Cremated Remains
Other arrangements-Please specify:--- -_-..--_---------- -- -
XXXXX
If putverizati)n of cremated remains is requested,check here---
Revision:January 1,2006
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Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"signed by the nearest next of kin is necessary 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 Cemetery and 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 are, or are not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
Burial Transmit Permit and Authorization to Cremate Form. The cremated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a $30.00 charge
for this service.
6. Cremation,Administration Costs and Recording Fees:
Adult $325.00
Children (age 13 months to 12 years) $175.00
Infants (stillborn to 12 months) $125.00
Overtime Cremations(Weekdays) $450.00
Saturday Cremations $450.00