Chandler, Patricia T07+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-IT
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Name PA21LL et—
CAMD,C. Case #i
Date of Cremation_ _ 7
Time Cremation Started / 3 • /1'1 I
Time Cremation Completed _I 3s A-' fy)\
Type of Container Joop
Remarks :
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TOWN OF ❑UEENSUURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) Crematorium 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 :
(Name) (Sex )
(Street ) (City ) -T (State) ( Zip Code )
L!Ir 97
who died on 7 day of (AL 19 _
at � �"S / 7wcS
(Place) (Address )
Nam,e; and , address of nearest living relative or name of person
authorizing cremationl�y
" ,f urTD�✓ C /�. YNiY �-
(Name) (Addres n) -�G
R e ha t i,o.n s,h i p .t o the deceased a�1(,�&,/4/ /�L
Na rw e of Funeral Home ye)L- il� l� /►//�1� /"G _ L �� �1�� � t
IMPORTANT:
e �nt that to the best of my knowledge, the deceased has or
has no aCemaker in his or her, body. (Circle One)
I' cert:ify''"that I have the full power and •aut:horization to arrange
for' thre' cre►nati'on 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'Vimand'sl.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
ground s's;` �fal se rau ent .
(Witness ) (Address )
(Signature of Relative or Legal Rep. and Address)
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
remains. accompany the
4• , All" remains must be encased in a cast<et or suitable alternate
y ' container. Caskets and containers must be of combustible
wa;t�eri�a'l" No styrafoam or plastic containers will be accepted.
5. •t The question relative to cardiac pacemakers must be answered
one° the•"autt,orization' to cremate form before the remains will be
acc'eP't ertd. �`.
bar' ' Unless 0ther arrangements are made the cremated remains will
be mailed -via Registered U. S. Mall within three days of cremation
to the funeral home handling the service. There will be a s20, 00
charge.-for- this service.
Cremation, Administration Costs and Recording Fee : -Adult s
ChJJdr,en.,.,, .(age.. 13 months to 12 years ) fl ] 185. 00
•0. 00 Infants ( stillborn
to 12rmonth's )tsl;s'j0. 00
: .
oroKi�r AUTHORI
HERE ZATION FOR CREMATION AND DISPOSITjON
THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAR FU CREMATION.
uWe,the undersigned, certify,warrant and E LLY BEFORE SIGNING
disposition of the remains o _ represent that I/we leave the full le al
j r $ right and authority t authorirz,e the cremation,processing and
Name o eceae (here�ter referred t as the"Deceased>,
Date of Death r )'
I/We hereby request and authorize `?�'' ' . ;r
' M.Time of Death �'_ ( ❑A
f (hereinafter referred to as the"Funeral Home")o
take possession of and make arrangements for the cremationFo a Home
(hereinafter referred to as the "Crematory"). f the remains of the Deceased at :"
authorize the Crematoryto 7-
Me �
understand that h return the cremated remains Of the Deceased to thepossession , d Name o Crematory
e services and obligations of the Crematory shall be an custod of the Funeral Home. I/we
the possession and custody Of the Funeral Home. I/We hereby authorize ful hll d when Home to the as aremains rms for the a Deceased are returned to
remains of the Deceased as follows:
Is special handler required? spoeition of the cremated
$ ❑Yes LAN° Describe
Description of urn or container selected: &Z./i ,y-
❑ Deliver to ` > Suitable for shipping: 0 Les ❑No
❑ Release to family Name and Address of Cemetery Cemetery
El Scattering at sea by Funeral Home or Funeral H 'nt�Fam,ly Member to Receive Cremated Remains
❑ Ship via U.S. Registered Mail* ome s agent
To: Name:
❑ Other Address:
' Funeral Home and Crematory are not responsible for any lose or damage of cremated remains shipped via Registered Mail with the U '
States Postal Service.
rated
The cremation, rocessing and disposition of the remains of the Deceased authorized herein s
governing laws,�e rules,1e$ulations and policies of the Crematory and Funeral Home, and the followinbetermsonned in accordance with all
1. The remains of the Deceased will not be accepted for cremation unless $ and conditions:
creation container The Cremato ess received by the Crematory in a combustible, leak resistant, rigid
Crematory 's authorized t remove and dispose of handles, ornaments and any other noncombustible items
attached to the cremation container prior to cremation. In the event the re
or other container constructed of metal, fiberglass or other noncumbustibleamaterials,
of the Deceased are received by the Crematory in a casket
removed prior to cremation and placed in a combustible creation container. I/We f lrtlI we authorize the remains of the Deceased to be
make disposition of any such noncombustible casket in any lawful manner it deems appropriate.
e authorize the Funeral Home or Crematory t
2. Mechanical or radioactive d
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 t e of
im lanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
aut orize the Funeral Home, its agents and employees, to remove any such mechanical devices from the r
emaprior to cremation, and se of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OFSTof td
HE DEDCeEASED
DO 0 DO NOT t/ I WNT�J ANY TYPEF OF IMPLANTED MECHANIC
Please initial one. I 1 AL OR RADIOACTIVE DEVICE.
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
escription 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 laced in the cremation chamber
i �'13' by Prolonged exposure to intense heat and direct flame. I/We authorize the Crematoryt open
and will be totally and
during the cremation process and reposition the remains of the Deceased in order t facilitate a complete and thorough the creation chamber
4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental filling,,re jewelry,
personal articles accompanyingthe remains of the Deceased, may be destroyed during the cremation rocess. I/We further
authorize that if any items, oter 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. niot t d to,hy authorize
the latcrCrematory to and remove from the cremation chamber all noncombustible materials, including, but
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 he mechanically pulverized to
an uniden, ahle consistency prior to placement in an urn or other container.
7. Unless an u ---fir container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in
-- . 1 1f r I .
"Customer's Designation of Intentions"
Name of Deceased: !,2 1:*M A�y ,ter10 f�j
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
Y D Return to Family
9j Burial at V-) ".-Ij
Other (spobify):
El Entombment at El
i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
j A,,\i(-, Li L
(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 Signature of 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 YEIJD'W-Family Copy PINK:Crematory Copy CUSUMN Rev.4/96