Bapp, David rrnWN, OF QUEEN,5BUP� ''
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name C a s e it �1
Date of Cremation l `
Time Cremation Started ;7 3 Q �
Time Cremation Completed 1 yLl
Type of Container S 7z ' a` LAst�C� Cit51% O� TJ�i
C' Q Ito 1—�vc
Remarks :
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ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAIN&IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. RFtDThiS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, certify, t and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o �� , _ (hereinafter refened to as the"Deceased").
ame o Decease l
Date of Death �� Tnne of Death ` ' ' l A.M. ❑P.M.
I/We hereby request and authorize ( C4t (hereina e_r referred to as the"Funeral Home")to
ame Funs me l \
take possession of and maize arrangements for the cremation of mains of the Deceased at `
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we
undesthepossession to
and custodt the ys and of the Flunations eral Home.e.eI/W hCrematory
eby authorize Fun when
era Hom t arrange for the dispoe Deceased
the are cremated
Y
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: (')G (— Suitable for shipping: Yes ❑No
❑ Deliver to Cemetery
i I�Tame and Address of Cemetery
Release to family ( -,3C�_-f
Name of bes4nated Family Memhe to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Slup via. U.S.Registered Mail*
To: Name: Address:
❑ Other
Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United
States Postal Service.
Thecremationlaws eoces rules, and
disposition
e remains of the crematory the Deceased authorized herein shall be performed in accordance with all
governing g policies ry d Funeral Home,and the following terms and conditions:
1. The remains of the Deceased will not he 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 other noncombustible items
attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket
or other container constructed of metal, fiherglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to
make disposition 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 hazard
When placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of
implanted mechanical 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,=nu U
se of such items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO T CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial on
Listed below are all impUtited mec a�#cal and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,and dispose oof as indicated:
Description of Implanted Device Disposition
Description of Implanted Device Disposition
If no instruction for disposition is given, such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will be totally and
irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber
during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. j
4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other
personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further
authorize that if any items, other 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.
5. I/We hereby. u��s,latches, nailer jewelry and p to separate recious metals,and to dispose of su remove from the cremation heh�mater anll'als.ncomhustihle materials, including, but
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 urn 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.
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
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TOWN OF UUEENSUURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
-7mate .11the emains of :
_
(Name) (Sex)
av C � ) ) M
(Street ) (C1 y) (State) ( Zip Code)
who died on l�1 day of Vw 19
a t
(Place) t ddre )
I
Name and address of nearest living relative or name of person
authorizing crema n :
(N e) ( ddress)
Relationship to the deceased _
Name of Funeral Home QC- r
IMPORTANT:
I rF- resent that to the best of my knowledge, the deceased has or j
as no--Pacemaker in his or her body. (Circle One)
I certify that I have the full power and -authorization 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 loss or damages which may be made against them by
reason of or connected with the cremat:.io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or Fraudulent .
I
(Witness ) (Address )
I
(Signs re of R'elatVi4e or Legal Rep. and Address)
Signed on this date :
I
Y(vd
Yo-4 2t14
a ,
4 T8j 79' 111-1
"Customer's Designation of Intentions"
Name of Deceased: Y . -r-)
Cremation: i
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at )(Return to Family
El Entombment at 0 Other (specify):
hereby designate the Disposition of Cremated Remains and acitnowledge receipt of a copy of
this form.
Signature)
(Printed NTe) j. (!Rela ship to Deceaoed)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columharium."
ry
Printed N4,ne of Funeral Director Signs of Funeral Director t)ate
o Undertaker
Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: Victual Date) (Location of Crematory)
Disposition of Cremated Remains: (Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELIDW Family COPY PINK:Crematory COPY CUSIMN Rev.4/96