Seminsky, Ethel r-r
OF
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PINE YI E'R� ERY`�.' E E.��B1�
. CEMET AND CREMA
QUAKER ROAD. QUEENSBURy TORIUM
(518) 74S-4.476 NB 'V YORK 12804
(518) 745-4,477
_ I Funeral Director n
Date Of Cremation Case#. fy-�
T ;me Cremation
Started
T ' me Cremation Completed
Type of Container I
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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. Ethel Seminsky Female
(Name) (Sex)
9 Haywood Avenue, Rutland,Vermont 05701
(Street) (City) (fie) (ZJp Code)
who died on 5 t h day of Ap r i l 20 O 8
at Mt. View Center Genesis Eldercare,Rutland, Vermont
(Piece) (Address)
Name and address of nearest living rate"or name of person wjJwrb*V cremation:
Dolores Park, 1036 Main Street, Castleton,Vermont 05735
(Name) (Address)
Relationship to the deed DAUGHTER
Name of Funeral Home Durfee Funeral Home, 119 No. Main St,Fair. Haven,VT 05743
IMPORTANT:
I represent that to the best of my knowledge,the deceased"0 no ,delibrillator,beflary,battery peck,power
cell,radioactive implant or radioactive device in his or her body.( e e)
1 certify that I have tug power and sudwrtzatlon 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 meson of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
( ) )
(Sigrneture and Address of Relative or legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other anarngemernts_Pleesespediy' Durfee Funeral Home will return for Cremated Remains
if puNertzation of cremated remains Is requested,check here XXXXX
Revision:April 18,2DO7
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 authorb:ation in
addition to a regular burial permit must accompany the remains.
3. Ali remains must be in a casket or suitable altemate container. Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Any cardiac peoenrakers,defibrillators, battery,battery pack, power veil, 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