Kelly, Marcie TOWN OF QUEENSBURY
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:
(Name) (Sex)
(Street ) (City) (St `te) (Zip Code)
who died on day of 19 49-
at
(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
SULLIVAN,MINAHAN&POTTER
IMPORTANT:
GLENS FALLS NY 128014454
I sent 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, fals or fraudulent.
A�
(Witn eA s) (Address)
Signature of Relative or Legal Rep. and Address)
Signed on this date: /g�9
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to C
Other arrangements - please specify :
If pulverization of cremate 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 oi, 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) $10. 00
4 '
° ' AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.1094
NOTICE:THIS IS A REGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We, the undersigned, certify, warrant and represent that 1/we have he full legal right and authority to authorize the cremation,
processing and disposition of the remains of -
(hereinafter referred to as the"Deceased'). Name or Deceased
� Da of D �_ElA.M. c�P.M.
I/We hereby request and authorize Death �9 Time of Death��R �f� tereinafter referred to as the"Funeral Home")to take
Name o!Funeral Home �
possession of and make arrangements for the cremation of the remains of the Deceased at�/1 .X
(hereinafter referred to as the"Crematory'). Name of(remuory
[/We 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? El Yes I N/
o Describe
Description of urn or coots' er selected: Suitable for shipping: ❑ Yes ❑ No
ElDeliver to
Name and Address of Cemetery Cemetery
❑ Release to family
Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via
To: Name Address
❑ Other
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 non-
combustible 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 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, and dispose of such it s at its discretion. [/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT P 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
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.
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 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
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 nartielpe of the erPmutad ramainc of tho rl—....A --A ♦I_*
AUTHORIZATION FOR CREMATION AND DISP 031 Rev.10/94
DISPOSITION
N TICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVEk'SIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BE ;ORE SIGNING.1/We, the undersigned, certify, warrant and represent that 1/we have the full I al right and authority to authorize the cremation,
processing and disposition of the remains of f, Z .
(hereinafter referred to as the"Deceased'). —� NameofDeceased
Da of Death "� '>9�� Time of Death
I/We hereby request and authorize .a - ❑A.M. R1 P.m.
;dam' (hereinafter deferred to as the"Funeral Home")to take
Possession of and make arrangements for the cremation of the remains of the Deceased ate') y,.� ,���
(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 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 L"No Describe
Description of urn or container selected: Suitable for shipping: ElYes ElNo
❑ Deliver to
Name a d Address of Cemetery Cemetery
❑ Release to family
Now of Design
❑ Scattering at sex by Funeral Home or Funeral Home's agent Family Member to eeee;"`crem.ted Rem.;ns
❑ Ship via
To: Name Address
❑ Other
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 non-
combustible 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 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, and dispose of such It s at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO C1 DO NOT k 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
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.
4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental ffBings, 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 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
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 norrihle to rornver all -"-I- ..f al.. ---...----a __.Y____ _e