Gussow, Kenneth OF
PWE V1E Q EE9�SB Ur
'�' CEMET
QU ERY AND CREM r`J
A YER ROAD, Ql1EpNS8 ATORIUM
(518) 7'QUE 6 URY, NEW YORK 128p4
1"44 (518) 745.•4477
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Town of Queensbuty
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 audimttes Pm View Crematonurn,in a000cdanom with and subject to its Rules and Regulations to
cremate the remains of:
Kenneth Gussow Male
(Name) (S84
27 Monte Vista Dr. Warrensburg, NY 12885
(meet) (CRY) (State) (ZIP Code)
who died on 7th dyof September 2008
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living releo+re or rem of person aumonzuV crernaaort:
Rochelle Gussow 27 Monte Vista Dr. Warrensburg
(Name) (Address)
Relationship to the deceased W i f e
Name of Funeraltiome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the hest of my kmowtedge,the deceased :sn5d j�,deftallwor or any other battery operated
device In his or her body- (Circle One)
I certify that I have full power and a It horizegon to arr Qe for the aemation of the remains and to direct the disposition of the
cremated 111ii,11111em thatart�LpereanetPossessions have either bean removed or may be destroyed,and agree to Wota,defend and
save harmless �. torfum from arty and 88 cairns and dwtartds for loss or dosages which may be made against them
by the cremation of said remains as drreMid,whe0ter such dahm or demands are or we not wholly
9
(Address)
77,Y" ,'
( Relative or Legal Representative)
Signed on this date: September 8 , 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as toilows:
Mali to
other arrangements_Please specify: Funeral home will pick up
If pulverization of cremated remains is requested,check here X
Revision:Jyl�, ON
18 07
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
crematorium operates Monday through Friday from 7:00am to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation'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. Cardiac pacemakers,defibrillators or other battery operated devices must be removed
before any remains will be accepted-
S. 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 charge
for this service. •
6. Cremation,Administration Costs and Recording Fees:
Adult $366-W- .33"•
Children (age 13 months to 12 years) $39G.- 8' f go
Infants (stillborn to 12 months) D9-80� /3 -`j3