<p> Humane Society of Pagosa Springs – Public Cremation Details Form</p><p>Animal’s Information:</p><p>Species  Canine  Feline  Other ______Name: ______Breed: ______Color: ______</p><p>Weight Private Cremation Fee* Communal Cremation Fee** Less than 25 lbs  $115  $50 25 - 50 lbs  $140  $65 51 - 75 lbs  $165  $75 76 - 100 lbs  $190  $90 More than 100 lbs  $220  $110</p><p>Animal’s actual weight: ______</p><p>Owner’s Information:</p><p>Name: ______Phone#______Phone#______Address (physical) ______City______St______Zip______Address (mailing) ______City______St______Zip______Special Instructions: ______</p><p>*Private Cremations: All private cremations include your pet’s cremains returned to you in a hand-crafted Wooden Urn with your pet’s name engraved on a brass name plate.</p><p>**Communal Cremations: Do you wish to have your pet’s cremains returned to you?  Yes  No Cremains will be returned in a clearly labeled sturdy cardboard container. If you do not wish to receive your pet’s cremains they will be lovingly scattered in our Serenity Garden. To receive information on purchasing a Wooden Urn please check here , or visit our website at www.humanesociety.biz </p><p>Memorial Bricks: Purchase a custom engraved brick in memory of your pet (or other loved one) to place in our Serenity Garden at the Animal Shelter. Please check here  if you are interested in receiving additional information, or visit our website at www.humanesociety.biz </p><p>Office Use Only:</p><p>Receipt Date: ____/_____/_____ Received by: Date Paid:_____/_____/_____</p><p>Method of Payment:  Cash  Credit Card  Check #______Cremation Date: Veterinarian assisted?  Yes  No ____/_____/_____ Urn Size: Small Medium Large X-Large Box Size: Small Medium Large Date of Owner Notification: _____/_____/_____ Notified by: Spoke with: Date of Cremains Pick-up: _____/_____/_____ Signature of Person Receiving Cremains:</p><p>Date Faxed/Emailed to Admin____/____/____ by ____.____. Date Posted____/____/____ by ____.____. Rev. 5/14/17</p>