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Campbell, Baby Boy rl-o q+N OF QUEENs5BUWY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 ,ram Funeral Directors1 � p� Namely Case # � Date of Cremation 10 — a-3 — 9<� Time Cremation Started /c;L1 ;L� P/M r i Time Cremation Completed Type of Container G'/9�C'- A� ���� c/95�• d � �1��j Remarks : /o� i4MrJ7,r /4 f TOWN OF ULIEEN9HURY p INE V IEI4 CEMETERY R CREMA MMM Quaver Road, Uueensbury, New York 12804 Phone (518) Crematorium 775-44776or if no answer Cemetery AUTHURIZAMN TU CREMATE in The undersigWi�hraQ�eSsub�jectautooitse,Rples view and Regulations' to accordance , cremate the remains oft (SON) L+—g� (Street ) (city) c9tate ( Zip Code) � who died an ______Z�/7 7 " ' ' a y o F at (Address) )Place Name and address of nearest living re latiV� or naMe of ptr�ori authorizing crematsont )Name) (Address) Relationship to the deceased Name of Funeral Nome IMPURTFINts knowledge, the deceased has or I represent that to tlts best of my (CirclO Une) a�50as no pacemaker in his or her body. f2atiOh to ge I certify that I Have therpnurainsoand tower d direct rthe disposition Of for the cremation of the persons possessions have either the cremated remains. that any P rotect, defend been removed or may be destroyed, and agree to Pal and save harmless pine vaeia esewhichimayum fbemmade against any and andand demands for loss tp d g the cremation of said remains as reason of or connected with directed, whet er such claims or demands �;re or are not wholly g,- "dives-so f se or fraudulent. c (Address) W ( ss) 128�1i �ne (Signature of Relative yr Legal Rep, and. Address) Signed on this dater lam/ �'/ DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify: If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1 . The crematoriu?n will be open for cremations 5 days a week 7 : 00 A.M. - 3 : 30 P .M. Monday-Friday. No Holidays or Sundays, arrangements can be made , for Saturday. Prearrangements by telephone for acceptance of remains is necessary. 2 . Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, 'Town of Queensbury. 3 . An authorization for cremation properly signed by the nearest next of kite or other authorized person 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 Crematorium from any and all claims and demands for lose 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 or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular burial permit must accompany the remains . 4 . All remains m4.gt be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material . No styrafoam or plastic containers will be accepted. 5 . The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6 . Unless other arrangements are made the cremated remains will be mailed via Registered U. S . Mail within three days of cremation to the funeral home - handling the service. There will be a $20 . 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $195 . 00 Children (age 13 months to 12 years ) $.115 . 00 Infants (stillborn to 12 months ) $75 . 00 * Additional $50 . 00 charge for cremations done after 3 : 00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50 . 00 . Sullkan-Minahan& pow407 , C1t�eensbuBaN Rd ry 1 2804 "Customer's Designation of Intentions" •� � !t�' Name of Deceased.:_ �.;'�x•�� (4 �' y Cremation: r �� (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: ❑ Burial at 'Oeturn to Family ❑ Entombment at I ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of•a copy of this form. (Signature) tt Cf (Printed ame) (Relationship to Deceased),-, S l (Telephone Numher) :'T7-t—Ej "Cremated. Remains which shall not have been claimed. within 120 days`{turn'•the sate of cremation may be disposed of by this firm by placement in a columbariiimn .:L;�=I��7 Printed Name of Funeral Director S' nature of Funeral Director Pate �— or Undertaker x or Undertaker t" 'l TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED,REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) t (Location) (Date) Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 u . XK BOOKLET AL IORIZATION FOR C ON AND DISPOSITION MA THIS IS A LEGAL DOCUMENT, IT CONTAINS IMPORTANIONS CONCERNINGATION IS IRREVERSIBLE.AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING gned, certi{y, t and represent that I/we have disposition o f the remains o the full legal right and authority to authorize the cremation processing and ame o D E (hm referred to as the"Deceased"). I/We here Date Death A°A°if Tune of Death by request and authorize ❑AM. ❑PM. Name o Fun Home (hereinafter referred to as the"Funeral Home")to (htake possession of and make arrangements for the cremation of the remains of the Deceased at r , ereinafter referred to as the"Crematory"). / I/We authorize the Crematory to return the cremated mains of the Dec Name o Crematory e crema re eased to the possession and custody of the Funeral Home. I/we understand that the services and obligations o e ry y the Possession and custody of the Funeral Home. I/We heeby authorize Funeral Home to ed remains of the Dec f the Deceased as follows: arrange for the disposition of the cremaated remains o Is special handling required? ❑Yes ® No Describe Description of um or container selected: ❑ Deliver to Suitable for shipping: ❑Yes ❑No ❑ Release to family y Name and Address of Cemetery Cemetery ,, p - f 7,4►�.�fsF'// Name of ElScattering at sea by Funeral Home or Funeral Home's gentsigrias Farnrly Me=nberto Rec eive Cremated Remains ❑ Ship via U.S. Re ietered Mail+ To:Name: Address: ❑ Other ' Funeral,Home and Crematory are not responsible for any loss or damage of cremated remains sbipped via Registered Mail with the United States Postal Service. The cremation, processing and disposition of the remains of the Deceased authorized herein shall governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the foll bg terms and conditions:e erformed in with all I- The remains of the Deceased will not be accepted for cremation unless received-by the Crematory in a combustible, leak resistant, rigid cremation container: The Crematory is authorized to remove and dispose of handles, ornaments and any attached to the cremation container prior to cremation. In the event the remains of the Deceased other noncombustible items or other container constructed of metal, fiberglass, or other noncombustible materials are received by the Crematory in a casket eceased to be removed prior to cremationdand placed in a combustible cremation container: I/We further authorize the Funeral Hoorize the remains f to or)Crery to make sposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazy When placed in the cremation chamber. The Crematorywill not cremate an hazard im lanted mechanical y human remains which contain any type of p or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT [>, CONTAIN ANY TYPE OF IMPLANTED MECHANICAL,OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: -- -D-eription of Implanted Device Disposition Description of Implanted Device Disposition - If no instruction for disposition is given,such items may be disposedvof_at the discretion of the Funeral Home. a 3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally andirrevers . ' fly destroyed by prolonged exposure to intense heat and direct frame. I/We authorize the Crematory to open the cremation chamba.during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillips jewelry,fillings, j ry, and other personal articles aceompanyin the remains of the Deceased, may be destroyed during the cremation process. I/We further : t' authorize that if any items, o er than the cremated remains of the Deceased, are recovered from the cremation chamber, they may be separated from the cremated remains of the Deceased and disposed of by the Crematory. 6. limited authonize,the hinges,latches,nailer to separate and remove from the cremation chamber all noncombustible materials, including, but not precious metals,and to dispose of such materials. 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an um or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment.