Deppe, James OF
QUEEVBU-R,, y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case #
Date of Cremation Lc-St
Time Cremation Started
Time Cremation Completed
Type of Container `fj pai� owar
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Remarks :
Am ova
I�:IS�A
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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:
James W. Deippe Male
(Name)
375 Goodman Road Johnsbur Ny
(Street) (City) (state)
Rip Code)
who died on 9 t h day of August 20 09
at Glens Falls Hospital , Glens Falls NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Address)
Relationship to the decreased Ij i;SC
Name of Funeral Home Alexander-Baker Funeral Home
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)
I certify that I have full power7a,
tion to arran for the cremation of the remains and to direct the ciscremated remains,tposition of the
Y Pssions have either been removed or may be destroyed,and agree to protect,defendand
save harm a View C any and all claims and demands for loss or damages whk*n may be made against them
by or connect n of said remains as directed,whether such claims or demands are or are not wholygroun false or ulen
LIRI
(Address)
(Signature and ddressof R61ative or Legal Representative)
Signed on this date August 10, 2009
Disposition of Cremated Remains
I hereby direct pine View Crematorium to dispose of the cremated remains as follows:
Mail to
OW atart mem_please specify: FH will pick up
if puh ft sttion of cremated remains is requested,check here X
Revisiam Ja my 1,2009
Policies, Rules and Regulations
1. Pine View Crematorium is lorratthdou h Friday from 7:OOam View
t 3:30pm. Prior telephone
crematorium operates Monday 9 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 nal f the remains
s
and to direct the disposition oof hecremated be y ed and agree t prains,that any otect defend and save
have either been removed Y
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.
d containers
3. All remains must be in material. No styrofoam oasket or suitable re container. Caskets n
must be of a combusts
rr plastic containers will 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 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:J
Adult
Children (age 13 months to 12 years) $200.00
Infants (stillborn to 12 months) $150.00
Overtime Cremations(Weekdays) $550.00
Saturday Cremations $550.00