Wamboldt, Gordon OF
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PINE VIEW CEMETERY AND CREMATORIUM
QUAXF-R ROAD, Q�fEFNSgURY emu, YORK 1280
(518) 745.4-476 (518) 745-4�77
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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 and authorizes pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of
Mr. Gordon Wamboldt Male
(Name) (Sex)
28 Cedar Street, Fair Haven, Vermont 05743
( ) (City) (State) (Zip Flo)
who died on l lth day of February 20 08
at 28 Cedar Street, Fair Haven, Vermont 05743
(per) (Address)
Nad address of nearest imW relative or name of person autlxAzing cremation:
S en zZ l),
(Nam) (Address)
ReWtioneMp to the deceased DAUGHTER
Name of Funeral Home DURFEE FUNERAL HOME, FAIR HAVEN,VT
IMPORTANT:
I represent VW to the best of my lvnowiedge,the deceased(has)or(has no)pacemaker,dellbrillator,battery,battery peck,power
can,radioactive implant or radioactive device In his or her body.(Circle One)
1 oe*brat I he"full power and authorization to artange for the cremation of the remains and to direct the disposition of the
crremated remains,that any personal possession's have eWw been removed or may be destroyed,and agree to"ect,defend and
save harmless Pine View Crematorium from any and an 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
false or fraudulent
e �i�, N
( and of Relative or Legal Representative)
Signed on this da February 11, 2008
te:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mau to
Funeral Home will return for Cremated Remains
Other arrangements-Please specify:
If pulverization 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 audm dzation 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,defitxiliators, battery,be"per, power cell, radioactive
imPIM 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 t D the funeral home
handling the service unless other artangernents 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 (stillbom to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00