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Jeroulis, Gregory 7O` N OF QUEEVBUPY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director '5 A4 I CL P, Name ECE © f Jr Case # LJ/0 Date of Cremat i cn Time Cremation Started Z'M le e Time Cremation Completed Type of Container wcgop Remarks : P c1Lg� Z AUTHORIZATION FOR CREMATION AND DISPOSITIONN TI :THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT'PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT'CAREFULLY BEFORE SIGNING undersigned, cey,w�r��nt and represent that I/we have legal rig and authority to authorize the cremation,processing and pn of the remains oT��Y= c1 (,r "T r Y d U 1 J (hereinafter retired to as the"Deceased"). 7- Name o Deceased /) Date of Death I`une of Death ��, �(� DA-M. �rm I/We hereby request and authorize (hereinaft referredVt� s the"Funeral Home")to Name o FuneralHome l take possession of and make arrangements for the cremation of the remains of the Deceased at t i C � C-t,•-4 V f✓� (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/we are erstand t the services and he Cremato Home. b rte Deceato sed l obligations �shall be e�eh en the ted fthepossssionand custody of the Fneral I/We heeyautthorizFunera Funeral or the disposition the cremated remains of the Deceased as follows: Is special handling required? ❑Yes No Describe Description of um or containqr selected: k5uitahle for shipping: ❑Yes ❑No Deliver to \ ` t Cemetery Name and ess of Cemetery [I 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 rocessig and disposition of the remains of th Deceased authorizd shall e perfrmed in accordance governing lalws,/de rules,nregulatioons and policies of the Crem toryeand Funeral Home,eaand the followinhg ermso and conditions: with all 1. The remains of the Deceased will not he 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 noncombustible 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 im lanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory wzjil not cremate any human remains which contain any type of im lanted 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. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 0 DO NOT 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 cf.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 he placed in the cremation chamber and will he totally and ineversihly 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. In/Weot�rehyto,authorize binges,hatches,nails,je elry separate and precious metals,and to m the disposeof such on r A noncombustible materials, including, but 6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments��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 ty�r•prre of shipment. 8. In the event the urn or container is ingiA*rian+ +n acrnmm A.+A all „f A. --.4-.A .o...,_ f I.L- Tle e.,—A ----- ---.__-_1 DISPUS,ItION 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 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. 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 hecording Fee: •Adu1t fIp5. 00 Children (age 13 months to 12 years) i11:0. 00 Infants ( stillborn to 12 months) $` O. 00 s 1 . TOW Utr oUEEiJ9�UhY PINE VIEW CEMETERY CREMATUA I UM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-447��,or if no answer Cemetehy "UtHURIZIIttUN TU CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to crema a the remain f: ,,,, Y,e (Sex) (Na e) 1(( G �fr (State) (Zip Code) (Street ) (City) day of 19 who died �onik4q]-- — at l 4 -el (Place) (Address) Name and address of nearest living relative or 118M6 of person aut prizing cremation: lac � '1111. d (Name) (Address) � rG' YG; &I to the deCea�ed_.___r__I�_ Relationship �- Name of Funeral Home--,5 IMPURTANT: hat to the best of my knpwledge, the decoAsed has or I represent t s or her body. (Circle dne) has no pacemaker in hi I have the full 'power and authoi^iiatibh to arrange I certify thatrect for the cremation of the'laremaiy5pergonal to dipossessionss have(either the cremated remains, protect, defend been removed or may be destroyed, and agree to and save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them by Ae on conriected with the cremation of said remains as whether such claims or demands are or are not wholly al audulent. ess) (Add ess) (Signature of Relative or Legal Rep. and Address) Signed on this date :