Davis, Benjamin Jr. Z "lq+N OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director n
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Name pin IC.- I/hJiS J �
Case# 3511
Date Of Cremation
Time Cremation Started
Time Cremation Completed 30
Type of Container �� rc� C 2 L
Remarks
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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 at
Mr. Benjamin Franklin Davis,Jr. Male
(Name) (sex)
130 Mansfield Avenue, Apt. 202,Burlington,Vermont 05401
( ) (City) (State) (Zip code)
who died on 13th dayof August 20 07
at His Residence; 130 Mansfield Avenue,Apt.202,Burlington,VT
(piece) ( )
Name and address of nearest Irving relative or name of person authorizing cremation:
Mrs. Mildred Davis 130 Mansfield Avenue,Ant.202, Burlington,Vt 05401
(Name) (Address)
Relationship to the deceased WIFE
Name of Funeral Home Durfee Funeral Home. ,Fair Haven,VT
IMPORTANT:
I represent that to the best of my Wwwledge,the deceased(has)or(has no)Pacemaker,defibrillator,battery,battery pa&,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
isposition
I certify That I have full power and personal
o possessions
to arrange eeither
he ha been matlon of the��or may be�destroyed,and agree t and to direct the o o"act, and
the
cremated remains,that any persona paassessior>s
save hermless 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.
(Wr) ( )
1 c l �'
(Signature and Address of Relative or Legal Representative)
August 13,2007
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- �:
If pulvwW ton of cremated remains is requested,check here
XXXXX
Revision:April 18,2007
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 overtime or Saturday cremations.
2. A 'Authorization to Cremate'form 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. Any cardiac pacemakers,defibrillators,battery, battery pack, power cell, radioactive
implant or radioactive device must be removed from the body 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 $330.00
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00