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Conroy, Ruth TOWN OF QUEEVBU-Ry PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name RV 14 C-o Q Re) Case # Date of Cremation Time Cremation Started Time Cremation Completed Type of Container ��� AS S Remarks : A1141/'N 90AWRW o g 1 �-`� 1? ,ten 116 12 2Q F±nl /-7 t� /� W.v - - °�' AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.10/94 N TICE: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, warrant and re esent that I/we have the full legal right and authority to authorize the cremation, processing and disposition of the remains of u 7`� (hereinafter referred to as the"Deceased'). Name ar Dmea,ed Dat f Death Time of Death ❑A.M. ❑P.M. I/We hereby request and authorize 4ell a�✓ nAli.4n1 C n Name of Funeral Home (hereinafter referre to as the"Funeral Home")to take possession of and make arrangements for the cremation of the remains of the Deceased at /^e Altkl (hereinafter referred to as the"Crematory'). Name of C"rematory 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 �No Describe Description of urn or container selected: Suitable for shipping: ElYes ElNo ❑ Deliver to nName and Address of cemetery Cemetery Release to family poN A/c(� A 4e 7 � S Q„e �,� Name of Designated Family MemAer�toReceivv Cremated Remaim ❑ Scattering at set 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 sucFne. s 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 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,.4estroyed by_prolonged exposure to intense heat and direct flame. I/We authorize the,-Crematoty_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 --A _-...._La- ,- _____.__ _rr __-.__r__ _f .L_ _______._J ______!__ L - fl__ - • .. .. . . . .. . TOWN OF QUEENS©URY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12a04 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 cre to the remains of: (Name) (Sex) gaek e e A)s6a /tea (Street ) (City) (St te) (Zip Code) who died on day of 19 at (Place) (Address) Name and address of nearest living relative or name of person a .'. a Norizin cre a4 tion • A L 2 (Name) 0 (Address) / Relationship to the deceased d/�► Name of Funeral Home �l' lx-VAIV 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 noW wholly g3rojundless, fa se or fr ulent. ,. J �.. 4 it s (Address) (Signature of el iv or aLegal Rep. and Address) ) /q 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) $10. 00