Ellis, Robert i
TO, WN OF Q UEENSB UR rt< Cemetery and Creurnlorrrrnr Y
27 Quaker Rond, Qrreenshtiry, NY.
(518) 74 5.44 76 12804.5902
hrfP//wNvNv.queensbury.nei (518) 74 5.44 77
Funeral Director: n 1{"
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Name of Deceased: �h1
Case Number. Z5
Date of Cremation: h( Z
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Retort:
ZN Time 5-
Cremation Started:
Time Cremation Completed: 3:
TYPe of Container: i Qc
Remarks:
Nntrrrnl 8enuty ... A Cool Place to Lrur "
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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 authort ws Pine View Crematorium,
Cremate the remains of In accordance with and Subject to Its Rules and Regulations to
Robert J. Ellis Male
(Flame) (SIM)
25 Second Street, Fair Haven,Vermont 05743
(Meet) (City) (State) (Zip Code)
who died on 19th day of May 08
20_
at Rutland Regional Medical Center,Rutland,Vermont
(Ph") (Address)
Name and address of nearest living relative or name of person authorw ng cremation:
Mrs Jane M_ Fllis
(Name) (Address)
Relationship to the deceased WIFE
Name of FuneralFlome Durfee Funeral Home, Fair Haven,Vermont 05743
IMPORTANT:
I represent that to the best of my kknowiedge,the deceased(has)or(has no)pacemaker,denbrfllMor,battery,battery Peck,Power
cell,radioactive implant or radioactive device in his or her body.(Ckrde One)
I Certify that 1 have fug 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 meson of or faseoornnected with the cremation 0mr said remains as directed,whether such claims or demands are or are not whoity
-e-�
V (Address)
a
( andl6drew of Relative or Legal Representative)
Signed on this date: May 2 0,2 0 0 8
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements_Please q)ecfy. Funeral Home will return for Cremated Remains
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 operatesfarce o�remaithroh Friday
ns are�rMeoessarY tPrearrangements arpehone
acceptance arrangements for the p
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 there 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 authorizedw 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 crerrradon to the funeral fame
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