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Leinoff, Celia Funeral Dirictor 9 Name 'Case Number M Date of Cremation Time Cremation Started Time Cremation Completed Type of container Remarks W' e4i!!::00000/f! Ir lee 1-5 A-7 mac/ '0 POE CREMATION RE L QUEST Permit No. _______________ To: Dated ------------------- 19---- Germeterq-A+renue---., Operated by: phone 463-?617 6ermetepy-Ayoi►ue The undersigned hereby requests and authorizes, in accordance with and subject to your rules and regulations as well as those of the State of New York to cremate the remains and casket containing same of -------- -__ -------�_Y _-____ who died at_z -z-e �r `�=f- ? -Y --• on the ____1 Q________ day of __ ���_�� 19 and certifies and represents that he or she has the right to make such authorization and agrees to hold the Crema- torium, Funeral Home and Funeral Director harmless from liability on account of said authorization. j � Witness:----------------------------------------- - -----�--------------=--------------------------- (Signature of Relative or Legal Representative) ----------------------------------------- Address_iL`L� y � �� _ U T�.�l ►� GLr�Vi ne �S Funeral Director t! _ city e S �x ��_ State Y-{ ------------- --- Firm----1 =�i -�r.� � r-- --------------------------------------------------- (What Relation to Deceased or Authority to Sign) INSTRUCTIONS Disposition of Cremains 7---------------- ------------------- - � �------- ---------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ----- -------- ------- , Authorized by ------------------------------------- Received the Cremains of the above named deceased this _____________ day of ------------------------ 19____ Signed ------------------------------------------- INFORMATION FOR CREMATORY RECORDS Name of Deceased ...... .................................................................................................. Late Residence ........kl:ex..... ....... ........................ ............................................ Place of Birth............................... ............................................................................. .......... Place of Death Date of Birth ...... ....... Dateof Death ................................................................................................... Age: Years ...... . ......... Months ................................ Days .......................... ............ . ...................................................................................................... Father's Name !. . . Mother's Name ......................................................................................................................................... ...... Married........................ Widowed ....... Divorced ................... Single ................... Name and Address of Near Relative Authorizing permission for Cremation ...... # d.............. I q, jS _x V5 ....... ...... .........................................................................J........... C .. ....A.. ...... gi k7 FuneralIn ........................................................ Day ....................... Date ................................. Time .................................lj Funeral Home Name ....................................................................... ..... . ..... ...41 ...................................... Address CREMATORY RULES AND REGULATIONS A request for cremation must accompany the remains and be properly signed by the nearest next-of-kin or other authorized person, in addition to a regular burial permit. Arrangement for disposition of the cremains must be made on the request form. Any cremains to be disposed of by the crematory cannot be reclaimed after two years. Remains will be received on a seven day a week basis between the hours of 8 A.M. and 5 P.M. by appointment only. The charge for cremation includes the use of Chapel during working hours is $110.00 which is payable on arrival. All remains must be encased in a casket or suitable container. (NO NON-COMBUSTIBLE MATERIAL WILL BE ALLOWED) will not accept any remains which have a Heart Pacemaker of any type implanted within. If this rule is not adhered to the person authorizing cremation will be responsible for any damage to our cremation retorts or personal injury which might occur. PUBLIC HEALTH LAW §4145. Deaths; burial and removal permits; disposition of remains. 1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made shall inter or permit the interment or other disposition of anybody unless it is accompanied by a burial,cremation or transit permit,as provided in this article. 2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any transportation company,which permit shall accompany the remains to its destination,where if within this state,it shall be delivered to the person in charge of the place of burial or other disposition. 3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment, cremation or other disposition. 4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and name and address of the funeral director or undertaker, which record shall at all times be open to official inspection. ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES 2 I certify that the remains were disposed of in accordance with the permit on the reverse side on J —6`1 (Date) (Place of disposition and address) Section 4 Lot No. Grave No. Signature Title �"� ���� ,7,