Gregory, Florence To%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case #
Date of Cremat i cn �T
/�
Time Cremation Started q/t/11 AIA40
Time Cremation Completed m ''49
J1gfn ,
Type of Container
Remarks :
"Y3 4 10
11 �i Xd ,'off' i9„J)
ATTACH "AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CO CERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, ce ,warrant }� resent that have the full legal h and authority to authorize the cremation,processing and
disposition of the remains of�GLa JCS [ (y L�(}2 (hereinafter referred to as the"Deceased").
Name of DeceasedJ 2
Date of Death �/ �j' '7 Time of Death / 1- J.) KA.M. i�P.M.
I/We hereby request and authorize ! (+-i 4iV r IJJ�MAJAI (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home _ _
take possession of and make arrangements for the cremation of the remains of the Deceased at r'ttV l �4 -W
(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 custodyof the Funeral Home. I/we
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of theDeceased 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 1�1'No Describe
Description of u or container selected: _"'~'r"1
rn r }C iL o4, G4 Suitable for/ PP ahi mgI'es�' El No
Deliver to !�a y r/-1(f 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 le ,ne tdisposition of h remains of Deceased authorized herein following b e accordance with all
governing laws,thrulesgul regulations and policies of the Crematory and Funeral Home, a the s 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 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
males 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. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT 0 CONTAIN ANY TYPE OF IMPLANTED 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 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 he separated from the cremated remains of the Deceased and disposed of by the Crematory.
6 notlimitebd to,authorize
hinges,la latches,nails,jewelry and precious metalso and to dispose of ue Cremato to separate and remove frm the cremation hch materials.amber A noncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone 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
RIn AI P--4 A. -- r r n--4- ,*--- n 1— r .1 T 1 1
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 weelt
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 . -end 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 cumbustible
ater'il al" No styrafoam or plastic containers will be accepted.
0n4 `'The 'question relative to cardiac pacemakers must be answered
on`° the ''auth ,
,orization• to cremate form before the remains will be
accept ed.
y n ;; ;.,
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 s2O, 00
charge.-for- this service.
Cremation, Administration Costs and Recording Fee : Adult $ 105. 00
Ch,i.ldr.e.n,,,.,,.,,(age._ 13 months to 121 years ) sll•0. 00 Infants ( stillborn
to 12- monthls )'brs,70. 00
TOWN CUE QUEENSDURY
PINE VIEW CEMETERY A *,-)-V3
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (516) Cr°'e'matorium 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 :
Ae Az YE
(Name) - (Sex)
7� tau�C uS DUB 1 aS,37
(Street ) ) / (City ) (State) ( Zip Code)
who died on ! [ day of 19
at
(Place) (Address )
Na:me; and , address of nearest living relative or name of person
authorizing cremation : / s� 9
(Name) J (Address )
Rehation ship ,to the deceased A,6
Name 'orf Funeral Home ✓L �
;.,t;,
IMPORTANT:
pr sent that to the best of my knowledge, the deceased has or
has no acemaker in his or her body. (Circle One)
'I' curt-ify''that I have the full power and -authorization to arrange
`for' th'e' cremation of the remains and to direct the disposition of
the' cremated remains, that any personal possessions have either
been reaoved or 11
may be , destroyed, and agree to protect, defend
¢. . ). .r 7 *t. • ,. .,. 1
and . s'ave harmless Pine View Crematorium from any and all claims
and'`V m'ands -for"Ioss 'or damages which may be made against them by
reason of or connected with the cremat.•ian of said remains as
directed, whether such claims or demands are or are not wholly
groundles`s `' false or fraudulent .
4
v
(Witness ) (Address )
(Si ature of lat i e Jor Legal Rfep..�j and A dress) CJ
Signed on this date : ��—� l / / p�Q