Loading...
Bannin, Gerald T07+N OF QUEEVBU9ZY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director /t/1 je- Name Case # Date of Cremation / e Time Cremation Started br!J P4.,A4 t Time Cremation Completed Type of Container rJ60T_C,, /rET Remarks : -NX ci�i941/ca/�.T� / 14,16 1 11 l l `7/,a i41 All ' ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION ' BOOKLET HERE NOTICE: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 aid represent that I/we have the full legal right and authority to authorize the cremation, processing and disposition of the remains of 1�t 1 C� l if 7' �� (hereinafter referred to as the"Deceased"). Name of Deceas Date of D Tune of Death ❑A M. ❑PM I/We hereby request and authorize - �� .ir' — ''•' (hereinafter-xeeerred to as the"Funeral Home")to Name ot Funeral Home 1 take possession of and maize arrangements for the cremation of the remains o the Deceased at �lll U C �� (hereinafter referred to as he"Crematory"). Name ot Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to he possession and custod of he Funeral Home. I hall be remains o to theunderstandps possession and custodt the ys and of the Funeral al Hoions m the Crematory me. I/We herebysauhoorizzethe Fued neral al Hom to as nge for the disppositiond are of the returned r meted the pose sa y remains of he Deceased as follows: ,�, `� Is special handling required? ❑Yes o Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery Name and Address of Ce etery lease to family ' ( � 1 Name of Designated Family ember 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. remains of The over- laws,tEe rules,e ulat ans andon of oli i slof the Crem for yand Fune Deceased ral Home ea d the follo ll bg i s nd condition:erformed in accordance with all g g g P Crematory 1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leaf 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 he removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to maize 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 implante mechanical or ctive evice. In the emains the contain such a device, I/we erehy authorize t he Funeral Home, tsaagentsdand employees,event removerany such mechanical daces from the remains of the Deceased prior to cremation, and di!qV se of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 0 DO NOT CONTAIN ANY TYPE OF IMPLANl'ED 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 he disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will he 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 he 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 he separated from he cremated remains of the Deceased and disposed of by he Crematory. b n�y hereh hmited To,hinge,,thorize the latches, nails,jewelr to y and precarate ious metal remove s and tom the cremation diapoae of suhclmaterial,. allncombuetible materials, including, but 6. Following cremation, the cremated remains of he Deceased, consisting primarily of bone fragments, will he 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 he Deceased in a container which is not designed for any type of shipment. DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify:LUJIAC C al'� 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. 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 s105. 00 Children (age 13 months to 12 years) s110. 00 Infants ( stillborn to 12 months) $yO. 00 TOWN 1]i= riUE�NSaURY pINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New. York 12804 Phone (518) Crematorium 745-4471 or if no answer Cemet ei-y 745-4476 AUTHOR I ZiJt t ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cre to the rema' s of: C�-e r + (Name) (Sex) (Street ) (City) State) (Zip Code) w)io died on day of 19 l� at f- (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : 6-C (Na e) (Address) Relationship to the deceased �JUQ Name of Funeral Home IMPORTANT: 1 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 authoi^iiatibn to arrange for the cremation of the remains and to direct ctthedi 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 on connected with the cremation of said remains as directed, whether such claims or demands are or are not wholly gro dless, a s or fraudulent. LJ (Witness) (Address) c ( gnature of Relative or nLegal Rep. and Address) Signed on this dates ��� � `��