Kemmer, Robert To 7+N of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director i
Name � � �� "'`� � Case #
Date of Crematicn _��
Time Cremation Started / 1�� fm
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Time Cremation Completedx5:j l PItA ,
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PINE VIEW CEMETERY
Ii
UREMATUKIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetel^y 745-4476
AUTHOR I ZO t UN TO (AEMATE
The undersigned reague5ts and
authorizes
Rules View
and Regulations to
in
accordance with
d subject
crematle^ the re ains of:
C`1-U`tJi�l
(Name) 44�—(S
e
(Street ) x)
59 N -no UJ�e�� �1 AYE ama�'a� at 13 z i p
- � (City) ( tote) (Zip Code)
t )
who died an day of
19�
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) tAddrsSO
Relationship to the deceased__
Name of Funeral Home
IMPURTANT: ktlo Wled a athe deceased has or
es
ent that to the best of my (Circle dne)
tv*n_O>ace maker in his or her body.
I certify that I have the full 'power and authoi^iiatibn to
arrange
rect the ranon e
for the cremation of the remains dldipossessionsshave either
the cremated remains, that any persona
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
ins as
reason 0 f 011 wl-retherrlsuchd withclaims ore demandsoareoarsaare not id awholly
dir ,
groundless, false or fraudulent. .
(Witness) (Address) ,
gnature f Rela ive or Legal Rep. and Address)
`�7
XS1ed on this date : �a
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify s & (a/ ('o-
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, G)uaker Road, Town of Uueensbury.
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. 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, ' Admin: stration Costs and Recording Fee= •Adult $185. 00
Children (age 13 months to 12 years) $ 11,0. 00 Infants ( stillborn
to 12 months ) $'70. 00
X
AUTHORIZATION FOR CREMATION AND DISPOSITIONCE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
ned,certify,warra,4t and represent t at I/we have the full legal right and authority to authorize the cremation,processing and
isposition o te remains o �°<,;' / "{ �: ;rn�Y (hereinafter referred to as the"Deceased").
Name ot Deceased
D4e,of Death ! Lcl
e Tone of Death ❑AM. ❑P.M.
I/We�ereby request and authorizer 1 (hereinafter referred to as the"Funtral Home")to
al
an-an ements{(or the cremation o the r a of the Deceased at � ) V 1 C in, - tk A tk , .ter e take possession of and make g / t
(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 custod of the Funeral Home. I/dJ rte
are
to
unders
d that the
s and
ons of the C t
he
d when the
d remains o
the poss
ession ssionn and custody of the Funeral Home.Home. I/We hereb sauthoorizfetheFuneral om totar ae for the dispositiondof the returned
r meted
P Y Yg
remains of the Deceased as follows: �`
Is special handling required? El Yes I No Describe
Description of urn or container selected: \ Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
1 Name and Addreso f Cemetery
Release to family) (U l J� l t PYt MV i� - y:4�.�-{
Name of Designated(Family Member 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
* 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.
The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
govex laws, e rules,regulations and policies of the Crematory and Funeral Home, and the following terns 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 noncumbustible 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, an ispose of such items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL,OR RADIOACTIVE DEVICE.
Please initial one. li
Listed below are all implan ed mechal and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,and dispose of asicated:
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.
R T„ +hP PvPn+ +hP imn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: t
V
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at Xleturn to Family
11 Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Sig,ature)
(Printed Name) r (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signat re of Funeral Director Date
or Undertaker '-`or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96