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Henry, Margaret I TOWN OF QUEEVBUjr�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �j j/��,�,,� /� ",&— Name �Aff,-c' T iY Case # ,0!1 Date of Cremation Time Cremation Started Time Cremation Completed ��d� Fr I l r Type of Container � �e � i -%7J.4=— ©/= Remarks : �oo4w 031Rev.4/98 AUTHORIZATION FOR CREMATION AND DISPOSITION NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,warrkit and r0present that Uwe have the full legal right and authority,an no o no li iv n rso who a Teri r priority right under state law,to authorize the cremation,processing and disposition of the remains of ameo } (hereinafter referred to as the"Deceased"). Date of Death �5 1'�006 Time of Death A.M. ❑ P.M. I/We hereby request and suthori ^ (> eremaf")gter M as a "Funeral Home")to take Q.o ame possession of and make arrangements for the cremation of the remains of the at (hereinafter referred to as the"Crematory"). ameo rematory I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home. I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes X No Describe Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No ❑ Deliver to Cemetery K Release to family ame oi imsWmtea ramny menmer to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S.Registered Mail* To:Name Address ❑ Other a *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. .k The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: 1. 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 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,fiberglass,or other noncombustible 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.4 manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers,etc.) may create a haza>rc- 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 frodrthe 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 kCONTAIN 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 repiave from the t10 remains of the Deceased prior to cremation,and dispose of as indicated: * F 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 be placed in the cremation chamber and will be totally aio' irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cremation f chamber 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 fillings,�ewelry,and other personal articles accompanying the remains of the�eceased,may be destroyed during the cremation process.UWe 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 authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,including'd but not limited to,hinges,latches,nails,jewelry and 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 1 to an unidentifiable consistency prior to placement in an urn or other container. ,lk _, 7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the in a container which is not designated 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 remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container. 9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is .. . .. o _._, _e'1-- T........---1 .....t 4-u-t ......... ....s:..loo mn.. .norlvar•*anfly harnmp B TOWN OF UUEEN99URY DINE VIEW CEMETERY / R CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 775-44776or if no answer Cemetery 45-4 AUTHORIZATION TO CREMATE in The undersigned reenuOSgs and auos, Ping ules Vand Regulationsiew / to accordance with t to its R , cremate the remains off (Sam) (Name) l 19� l�` ra/ '6') � /rC1 (Street ) (City) (State) ( Z p Code) who died on day of at � . . . (Place) (Address) Name and address of nearest liVing relatiV# or name of pertori authorizing cremations (-,7PL-r 0A (Name) (Address) k. Relationship to the deceased , + Name of Funeral Home IMPORTANT: knowled e, the deceased has or I r esent that to the best of my )Circle One) as o pacemaker in his or her body. I certify that 1 have the full power and authorization' to arrange ion Of for the cremation of the ►' mannsperso�aldi possessions rect the shave teither the cremated remains, thaty rotect, defend been removed or may be destroyed, and agree to P and save harmless Pine View asewhichimaymatorumfbeaagainstany and l claims made thlby and demands for loss or damag reason of or connected claims ore demands oare oorsaare not awhoil ,+ di ected, whether s ch undless false fr udulent. �j n (Address (Witness) C 5 6k) A E I `J9 (Signature of Relative or Legal Rep. and Add SO) Signed on this dater 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 requeste , 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 crem"ion, of said remains and/or disposition of said remains as � difected, whether such claims or demands are, or are not wholly _` = endless, false or fraudulent. This authorization in addition to i.. 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 . 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 rer��ai:.s ::rill be accepted. 6. Unless other arrangements are made the cremated remains will be wailed 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. Crsmazion, 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 . "Customer's Designation of Intentions" jj Name of Deceased: C-7,/) L4-1 vv Cremation: (SAe".d Date)' (Location) Manner of Disposition of Cremated Remains: Burial at Return to Family n Ai it El Other (s-Pe I hereb jr designate the Disposition of Cremated Remains and acknowledge receipt of a copy,of this form. �(S�gnature) A 7n d fIllf-k (Pr (IR I tion ship to Dec'ea..d) (Printed 00) (relephone Number) 77 tic t . rema e4-- iiiff 9 which.shall not have been laimed within 120 days from the date of posed f by thi I e in co, mbarium. cxematip e o Wfirm. by ir M; hoc Director Director Signature of FnerJ Director Date or Undertalter OMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation. (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of F6son Making Disposition Signature Date #9 VHrM:Feral H.Copy YELLOW,Family Copy PM:Crematory Copy CUSINTEN Rev.4/96