Baldwin, John �O�v OF QUEE BUr
PINE VIEW CEMETERY AND CREMATORIUM
�y
WAXER ROAD, QijEENSgURy NEW YORK 128N
(518) 745-4476 (518) 745.-4477
Funeral Director
Fame —
vCa s e# 0
Dace Of Cremation TULL( 3
Tame Cremation Started j./D Q
Time Cremation Completed
Type of Container
Remarks
c�J Z 100
Z' 30
---------------
Cd�� 3 3c�Ph
T4
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 Regulatlons to
cmmate the remains of:
MR. JOHN GIBSON BALDWIN MALE
(Name) (Sex)
3 UNION STREET, FAIR HAVEN, VERMONT 05743
(Street) (City) (fie) (zip E�)
who died on 1st day of JULY 2008
at RUTLAND REGIONAL MEDICAL CENTER, RUTLAND, VERMONT
(Place) ( )
Name and address of nearest oft relative or name of person authormnp cremation:
MRS. CAROL CLARK, 307 SHERWOOD FOREST, EXETER, NEH HAMPSHIRE 03833
(Name) (Address)
Relationship to the deceased SISTER
Name of Funeral Home DURFEE FUNERAL HOME, FAIR HAVEN, VERMONT
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(Circle One)
1 certily that I have full power and authorization to avenge for the cremation of the remains end to direct the disposition of the
cremated remains,that arty 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 mesonot or corrrrected the cremation of said remains as drec;d�wlhC��er aairt�s or demands are or are not wholly
folsa®rphyql*ft.
eletivs or Legal Representative)
Signed onOft date: JULY 2, 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cmmated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
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 paoernakers,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