Dickinson, Velma TO'KN OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
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QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director
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Name Case #t k1 J/
Date of Cremation — 30 I /
Time Cremation Started
Time Cremation Completed
Type of Container 2-1VV16d62E0,P TiY�"or��
Remarks :
/41 Ai N ,(3y/�i��R o�! �•S'3 y�,n�
1 � 3 'All
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"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at kReturn to Family — 1
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
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(Signature)
(Printed Name) (Relationship to Deceased)
(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 Signaure of Funeral 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 YELLOW Family Copy PINK:Crematory Copy CUSRTMN Rev.4/96
ATTACH BOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOTICE; THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNINCuCREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o �C' ► l�>ti {�I; 1=i i 1 (hereinafter referred to as the"Deceased").
Name D
Date of Death �?� 1 Time of Death '' _❑AM. *M.
I/We hereby request and authorizer > � 'r� -- -�-t� �U (hereinafter referred to ae the"Funeral
Namec, Fune Ho e Home")to
take possession of and mare arrangements for the cremation of the remains of the Deceased at Hi Y',c_..
(hereinafter referred to as the "Crematory"). Name of Crematory y
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. /we
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of tCe Deceased 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 No Describe
Description of um or container selected: Suitable for shipping: ❑Yes ❑No
A9 Deliver to Cemetery
Xy7'� 7 + Name and Address of Cem ery ;^�
Release family i
ease to ;`,:, }d,rr1 ,�j � �-, --�`
� 2�� f'l � �` � y
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 cremation,�lrocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,the rules, regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
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 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
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. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT .CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implanted me 'cal 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. noeot lrhet bd to,rthorize binges,latches,nails,je elr to y and precious metals,anarate and remove from d to cremation
of sucmaterials.
noncombustible materials, including, but
6. Following cremation, 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.
0 T .1 .1 ff. . . . 1 . 11 f .1 . 1 f .1 1 1
DISPOSItIUN OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as followss
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 Oueensbury.
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.
S. 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 $105. 00
Children (age 13 months to 12 years) f11.0. 00 Infants (stillborn
to 12 months) s`70. 00
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TOW Or OUEENSBUhY
PINE VIEW CEMETERY
CREMATORIUM
Qual�er Road, aueensbury, New York 12804
Phone (518) Crematorium 745-44776
or if no answer
Cemetehy 45- 47
AUrHORtzattUH TU LaEMATE
in
The undersigned regUeSts subactautooitseS ine Rules View and Regulation Crematorium, to
accordance with and Je
cremate the remains of:
(Sem)
(Name)
) (State) (Zip Code)
(Street ) y
('/
who died on Z day of
e
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
m
22 7)a 'Yl
(Name) (Address)
Relationship to the defeated C S
Name of Funeral Home �^
I MPURTF1NT:
I represent that to the best of my knoWledge, the decoAsed has or
has no pacemaker in his or her body. (Circle dne)
I certify that I have the full 'power and authoi^liatibn to arrange
for the cremation of the remains and to direct
thedi spositionhave of
the cremated remains, that any personal possessions
er
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demarids for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
or demands are or are not wholly
directed, whether such claims
groundless, false or fraudulent.
(Witness) (Address)
(Signature of Rela ive or Legal Rep. and Address)
Signed on this dates 9 l GQ