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Washburn, Vera OF PINE YI QUEE9\�5�BUTry E`GY CEMETERY AND CREMATORIUM QUAKER ROAD, Q(jEE.NSBURY, NEW YORK 128C,4 (518) 745.4476 (518) 745'•4477 Name Funeral Director--.A q IIIPXk�`G�r W Cased =ate Of Crema t ion 60 - -me Cremation Started Te Cf ema t i on Comp 1 e t ed l � r ?e of Container (tirC oti�c,1 Remarks ©VF_ MA �; qS Town of Queembury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury,New York, 12804 Cemetery Office:(518)745-4476,Crematorium: (518)745-4477 Auttwriza*m to Cremate The undersigned requests and aultarizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: Vera Washburn Female (mane) (sex) 2404 St. Rt. 28 , Bakers Mills , NY (Street) (( Y) (state) (Lip Code) who died on 21 day of April 2007 at Glens Falls Hospital Glens falls , NY (Place) QWdress) Name and address of nearest tivM r eladve or name of person autfiommV cremation: Robert Washburn Bakers Mills , NY (Name) (Address) Relatiohip to fhe deed S o n ns NameofFuneralHiome Alexander-Baker Funeral Home, IMPORTANT: I represent that to the best of my Ivawledg%fhe deceased(%* r(has no)paeemel1w,delibrilator or any other beafty operated device in his or her body. (Circle One) I f that I have A&power and&MmrW tlon to arrange for ft cremation of the remains and to direct fhe dwosition of the cremated rwnaihs,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and save harmless Pine View Cnerrraf xkxn 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 retrains as direc k4 wthOw such deli is or demands are or are not wholly groundless,falser or fraudulent. Warrensbur / (Address) W ers Mills NY (Stwohwe and Address of Relative or Legal Representative) Signed an this date: 0 4/2 2/2 0 0 7 Disposition of Cremated Remaehs I hereby direct Pine View Crematorium to dispose of fhe cremated remains as follows: Max to Otiwarrangements_pgpeclfy; Rtn to Alexander Funeral home If pwhrermebw of cremated remains r.requested.check here XX Revision:January 1,2M Policies, Rules and Regulations 1- Pine View Crematorium is located on the grounds of Pine View Cemetery.The crernatcorium operates Monday through Fly from 7:00am to 3:30pm teleph . Prior one for the acceptanQe of remains me necessary. P genents are necessary for Saturday Cremations. 2- A `motion for Cremation,signed by the nearest next of Idn is necessary stating that they do have the arrange for the cremation Persons,of the remains and to direct thedisposMM rernwr My poss 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 � � said grains and/or won of said remains as directed,whether or are not wtw#y Bless,falseor ftwAWent This 8Uth0riZatbn 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 recupt Burial Transmit P,�mit and Authorization to Cremate Form.The of the be mailed via Registered U.S-Mail within three Of a'+errration to t�remains funeral he<rsal h will handlingtheservice unless other arc ome for this service. ngernerris are made.There will be a$30.00 charge 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