Brown, Rita T011N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1 /
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Name y0j /y/ Case #
Date of Cremation
Time Cremation Started 1 c7
Time Cremation Completed����rM �
Type of Container !//, 15 ��.��t`�C'11�
Remarks :
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TOWN OF OUEENSBURY �g
PINE
VIEW CEMETERY
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
cremate the remains of: r—
P
(Name) (sex)
(Street) /(City) (State) (Zip Code)
who died on day of 19
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Address)
Relationship to the deceased
l /
Name of Funeral Home
�Ill
'Lr
IMPORTANT:
to the best of my knowledge, the deceased has or
I represent that
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
direct , whether, such claims or demands are or are not wholly
ground s fal audulent. �`
!f� / / A/
(Witness) ,. (Address)
(S' nature of Relative or Legal Rep. and Address)
Signed on this date : /
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
I. 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. 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 $185. 00
Children (age 13 months to 12 years) $11,0. 00 Infants ( stillborn
to 12 months) $70. 00
deems appropriate. y
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, and dispose of such items at its discretion. I/WE 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:
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 and
irreversl y 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.
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 authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,
including, 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 to an unidentifiable consistency prior to placement in an urn or other container.
7. Unless an urn or container suitable for shipment iE 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
remains will be placed in a secondary container and returned to the Funeral Home, together with the primary urn or container.
9. 1/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts, it is
not possible to recover all particles of the cremated remains of the Deceased, and that some particles may inadvertently become
commingled with particles of other cremated remains remaining in the cremation chamber and/or other devices utilized to process
the cremated remains. 1/We hereby authorize the Crematory to dispose of any such residua, particles in any lawful manner it
deems appropriate.
10. Unless I/we give specific written instructions in this Authorization, the cremation, processing and disposition of the remains of the
Deceased will not be performed in accordance with any particular religious or ethnic customs.
11. In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days, the Funeral Home shall give written
notice to me/us by certified mail at the address(es) indicated below. 1/We agree that in the event the cremated remains of the
Deceased remain unclaimed, for a period of 120 days after the date such written notification is mailed, the Funeral Home is
authorized and directed to dispose of the unclaimed cremated remains of the Deceased in any lawful manner it may deem
appropriate.
12. 1/We agree to indemnify, release and hold the Crematory, Funeral Home, their affiliates, agents, employees and assigns, harmless
from any and all loss, damages, liability or causes of action (including attorneys'fees and expenses of litigation)in connection with
the cremation and disposition of the cremated remains of the Deceased, as authorized herein, or my/our failure to correctly
identify the remains of the Deceased, disclose the presence of any implanted mechanical or radioactive devices,or take possession
of, or make permanent arrangements for, the disposition of such remains.
13. Except as set forth in this Authorization, no warranties, expressed or implied, are made by the Funeral Home, Crematory or any
of their respective affiliates, agents or employees.
14. 1/We understand that this document does not contain a complete and detailed description of every aspect of the cremation
process. 1/We acknowledge receiving, from the Funeral Home, a copy of the booklet entitled "Cremation Facts" containing
additional explanatory information about the cremation process.
SIGNATURE OF PERSON(S) AUTHORIZING CREMATION AND DISPOSITION
1/We warrant that all representations and statements made herein are true and correct, and that 1/we have read and understand the
provisions contained in this doc ment, an4 jhl 1/we have received the booklet entitled"Cremation Facts".
Signature
Print Ntme Relationship to Deceased
Address Tel.No.( )
Street City State Zip
Signature Print Name Relationship to Deceased
Address Tel.No.( )
Street City State Zip
WITNESS: Date: , 19
} Signature � Print Name
Name and Address of Funeral Nome
WHITE:Crematory Copy YELLOW:Cemetery Copy PINK:Funeral Home Copy GOLD:Family Copy