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Knauss, Mary .a:1hk*.'rt To%N OF QUEENSB`Ll9ZY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director R F- .1 At D Name S Case it Date of Cremation Time Cremation Started Time Cremation Completed Type of Container © q!t G ►��j �f(^ 3►^ci C a se y Remarks : 01115i1997 23:08 518•-792-1287 RE52AN&DENNY #1346 rAUt 01 TOWN [IF QUEENSBURY PINE VIEW CEMETERY a CREMATORIUM Ovaker Road, dueensbury, New York 12804 Phone (516) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TU CREMATE The undersigned requests and authorizes Fine View Crematorium , in accordance with and subject to its Rules and Regulations to cremate the remains of; Mary G. Knouaa Lr"t Pao 0e#jwfS) femal --(Name) (Sex) Middle Line Road Ballston SPs NY 12020 i5treet) tG3ty) (5tate) (Zip Code) who died on 14th day of January 19 97 at RlPns Falls Hospital Glens Falls __New York- (Place) (Address) Nave and address of nearest living relative or name of person authorizing cremation: David piper 18 Jean Drive, Ashsbille, N. C, 28803 (Name) (Address) Relationship to the deceased. son Name of Funeral Home Regan and Denny I WORTANT 1 represent that to tnQ lest of my MnowleeJger, the decerased has or s no pacemaker in his or her body. (Circle Dnv) I Certify that I have the full power and authorization to arrange for the cremation of the renain.y arrd to direct the disposition of the I-emated remains, that any. personal possessions have either been emoY r may Ue destroyed, and agree to protect, defend and save harmless Rine View Crematorium from any and all claims and demands fur lwss or' dame.geti rehich way be made against them by reason of or connected with the cremation of said remains as air•errted, whether- such claims or demands are or are not Wholly groundless, false or fro ulent. ( i Hess tAc)dress) r (Si nature of Relative or legal Re'. and Address) Signed on this date: -- /+� 01/15/199 2�, 08 518-792-1287 BEGAN&DEr4NY 01346 PAGE 05 AUTHORIZATION FOR ;REMATION AND DISPOSITION °" '� `°�" L.THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. C�TiON IS IRREVERSIBLE AND FINAL„READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. i/We, the undersigned, certify, warrant and represent that I/we have the full leg right and aut city to authorize the cremation, processing and disposition of the remains of ___Ka14L�z.--Kna�sa-- (hereinafter referred to as the"Deceased"). rum tiDrard Date of Deatb 01/14/199.7 _Time of Death 10�_JS C1 A.M. f 1 RM. I/We hereby request and authorize Regan & MiZ".1 (hereinafter referred to as the"Funeral Home')to take me of Fw,enl Home possession of and make arrangements for the cremation of the remains of the Deceased at ,*XW of CreM100y (hereinafter referred to as the"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 autborize 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: ❑ Yes ❑ No CI Deliver to — Pina Vim _t-er / �Ql�aan�311r�, N Y Cemetery K.,r.�wire.or e«warr ❑ Release to family New of pWtnud FamYy MrMMe to Receive Creamed Reeu4n ❑ Scattering at sea by Funeral Home or Funeral Home's agent O Ship via To: Name __ Address ❑ Other The cremation,processing and disposition of the remains of the Deceased authorized berrin 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: I. 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 noncorPbvatible materials, 1/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 rior to cremation, and dispose of such items at its discretion. 1/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 0 DO NOT[ ] CONTAIN ANY TYPE OF IMPLANTED MECHANICAL 4R 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: Dnalp im of i"rmed Derkr —�..� o60dow M ppeelp$"of lmpund Device 0 ad d4m If no 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. S. 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 it secondary container and returned to the Funeral Home, together with the primary urn or container. a w of t not passible to recover all partic�es he cre matei remains of the Deceased, and�that•some particles may inadvertently becomecommingled with particles of other cremated remains remaining in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby authorize the Crematory to dispose or any such residua,' particles in any lawful manner it deems appropriate. 10. U"Iess 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. It. 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. I/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. I/We agree to indemnify, release and hold the Crematory, Funeral Home,their affiliates, agents, employees and assigns, harmless from any and all toss,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. B. Except as set forth in this Authorization, no warranties, expressed or implied,art made by the Funeral Home, Crematory or any of their respective aflilia.tes, agents or employees. 14. I/We understand that this document does not contain a complete and detailed description of every'aspect of the cremation process. I/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 I/We warrant that all representations and statements made herein are true and correct, and that I/we have read and. understand the provisions contained in'tb' document, and that I/we have received the booklet entitled"Cremation Facts". ' Signature David Piper San Num tune uuuooarip to Deeeaaet Address —pl i ,a-98803 Tel.No. -- tw�e cur state ila Signature MiK Nam* owlaueaaelj.w naeaanat Addr+e" - Tel.NO,( ) Street City --- 6ce W tt zip WITNESS. Date: titsnalnrc Print Name xame ant A"en or Fltneral Nome "I"M Cn-maawr Copy YELLOW:Cemetery Corry RINK!Fume)ttotne Copy G01.1>tlimtty Copy