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Moore, Raymond Ir '(Punerai Dirictoz r - Case Number Name -- Date of Cremation Time Cremation Started Ao Time Cremation Completed ___ _ Type of container r `Remarks X41 rf&EEWT- © /L > DENSMORE FUNERAL HOME,INC. 7-9 Sherman Avenue CORINTH.NEW YORK 12822 ' Phone(518)654-9285 IRVING H.DENSMORE,Lic.Mgr. CUSTOMER'S DESIGNATION OF INTENTIONS FOR DISPOSITION OF CREMATED REMAINS Full name of deceased \��"� *`t o k ` J M6 C) ( (Please PRINT Namel t( t thtlz V et 1 yfz•"C�i C \CVvti at �C7 ti�I l O'mot '�ti SCHEDULED PLACE OF CREMATION SCIPIEDULED DATE OF CREMATION The undersigned person(s)making arrangements request the Disposition of Cremains as indicated below: [ j Interment or Inurnment PLACE OF INTERMENT OR INURNMENT [ ] Release to: SPECIFIC NAME [ ] Ship to. SPECIFIC NAME STREET ADDRESS CITY&STATE ZIP CODE [ J Other: I(we)hereby represent that I am(we are)of the same of nearest degree of relationship to the deceased and/or are legally authorized or charged with the responsibility for the final disposition of his/her body,and that the above are my(our)instructions for the disposition of the cremated remains of the above named deceased.I(We)state that 1(We)understand that the cremains of the above named deceased may be disposed of in any lawful manner by the above named funeral home,if said cremains are unclaimed after 120 days from the date of cremation. Dated this day of 19 MR. MR. MRS. MRS. MISS MISS Address Address City and State Zip Code City and State Zip Code Phone Number Phone Number The undersigned Funeral Director attests to the following: (1) If the cremated remains of the above named deceased are unclaimed after 120 days from the date of cremation,said cremains will be disposed of in the following manner (2) A copy of the foregoing Designation of Intentions was given this day of ' 19 to the person(s)who made arrangements for cremation. tU --. n-I V1 4j-V'-.NR —AqZv 'It cliiCt~— SignFirs of Funeral Director Making Arrongments iltinted or Typed Name of Funeral Director The funeralal/fiirrm's copy of this Designation of Intentions will hereafter be completed to show � the following: Y\CA k'A I f -I.X� LAX V li-iA.l \ILC'V�.T Jtitit Actual bate of Cremation Name of Crematory Address r ' Cittirind State -- Zip Code Datkpf Disposition of Cremains �r LoG�t"ot of Disposition 4f Cremains Manner of Disposition of Cremains: Dated this )Iy� day of 19 Signature of Person Making Disposition of Cremains Printed or Typed Name of Person Making Disposition of Cremains • - • DISPOSITION OF CRENATED REMAINS I t I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangement - please specify: If pulverization of cremated remains is requested, check here POLICIES, RULES AND REGULATIONS 1. The crematorium 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 kin 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 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 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 must be encased in a casket or suitable alternate container, Caskets and containers must be of combustible material. 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. Cremation, Administration Costs and Recording Fee: Adult $125.00 Children(age 13 months to 12 years) 80.00 Infants(stillborn to 12 months) 45.00 Shipping container, carton and packing fee for shipping and registered priority mail with return receipt included in the above prices. ADDITIONAL SERVICE Storage of cremated remains-per month $ 2.00 TOWN OF QUEENSBURY ' PINE ,VIEW CEMETERY ' 8 CREMATORIUM Quaker Road, Queensbury, New York 12801 Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777 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: P.cam, .ti-�ti«" Y'hv vZ (Name) (Sex) t Li (Street) (City) (State) (Zip Code) who died on day of 19 at to v\ 'T' (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: (Name) (Address) Relationship to the deceased Name of funeral home �J IMPORTANT: �$ I represent that to the best of my knowledge,the deceased has or has 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 cremation of said remains as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent. (W ness) 7ignature of Relative or Legal Rep.) (Address) (Address) k iZ Signed on this date