Butler, Henry OF QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral orA�Qdd 0C 1016MNY
Name /iU Case # 0-� hf
Date of Crematicn
Time Cremation Started �fN) 1
1 Time Cremation Completed [OiQ 6 )`n 1 ,
Type of Container 1l1�17 � � / li✓Tcd:L�e,c:-
Remarks :
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a TOWN OF QUEENSDURY
PINE VIEW CEMETERY �
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) Crle'inatorium 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 :
LF
(Name) (Sex)
& / • , , S, rljo--S y /�86-3
(Street ) City ) (St t) ( Zip Code )
c.� G
who died on I day of J�/ 19
CA
(Place) (Address )
NaiTe and , address of nearest living relative or name of person
authorizing cremation : ,yq,3 „� H'LC
AA
'(Name) (Address)
Relationsh,ip .to the deceased
Nance b�f Funeral Home 2l62* b /Ok/Vi1j�
` IMPORTANT:
!:11 ent that to the best of my knowledge, the deceased has or
has n acemaker in his or her body. (Circle One )
I' certify'"that, I have the full power and •aut:horization to arrange
forth?e'' cremati'on of the remains and to direct the disposition of
the' crematred 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° 'demand's `for' loss 'or damages which may be made against them by
reason of or connected with the cremat.io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundles's;`''fal or f a t . /�y /gv>e
itness) (Address )
1011vk I�Zu C14;
(Signature of Relative or Legal Rep. and Address)
A
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
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 or suitable alternate
container. Casliets and containers must be of cumbustible
' materi'al" No styrafoam or plastic, containers will be accepted.
5: ,,� The question relative to cardiac pacemakers must be answered
on``' th'e ' auth`orization to cremate form before the remains will be
accept ed.
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 s20, 0(D
charge—for. th i s s ery i ce.
Cremation, Administration Costs and Recording Fee : .Adult Ch•i.ldre.n,_._,(age._ 13 months to 12 years ) s1 ] s1p5. 00
•0. 00 Infants ( stillborn
to 12= month's)t s`j0. 00
P �
ATTACH " -AUTHORIZATION FOR CREMATION AND DISPOSITION'
BOOKLET
HERE NOTIC THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION ISIRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
i/we,the disposition otliegn , cere�mains of ,/i d represent tba3iwe g and
Faye a full legal right and authority to here authom trize the cremation, processr referred to as the Decmeased
Name o Dec
Date of Da�+� y 1 Time of Death ❑A.M. ❑P.M.
I/We hereby request and authorize ` [,oa r Dr,Vtv7 (hereinafter referred to as the"Funeral Home")to
Name.1
Qe;J Home
take possession of and make arrangements for the creation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the created remains of the Deceased to the possession and cuatod of the Funeral Home. I/we
are
to
remains o
thepoe s'oesioln and custodt the ys and of the Funeral Home.ions e. I/We hereby authooriz shall be edtthheeFuheral Home to aen the s ange for the disposition dof the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes D�No Describe
Description of urn or container selected: C Suitable for shipping: ❑Yes ❑No
Deliver to �t / 1 Cemetery
Name and Address of 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 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
isposition of the remains of
rein
hall
goveeruing laws, erules,n regulations mans and policies of the Crematoryyand Funeral Home,yaand the following w bg terms performed
nd conditions:
with all
1. The remains of the Deceased will not he accepted for creation unless received by the Crematory in a combustible, leak resistant, rigid
creation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items
attached to the creation container prior to creation. 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, and dispose of such items at its discretion. ME HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT = CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Lasted 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 hherebyd to,hinges,thorize the
latches,nails,
jewelr to y and precarate ious us metals,and to dispose of remove from the cremation chamber
�such a{A noncombustible materials, including, but
not 6. Following creation, 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.
- , 1 - . - . . . Cf. . . . 1 . it r .1 1 r .1 n —- - — -- - — '-�