Ellis, Alderson Z��►��C, OF QUEErVBU9?(Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /�i�-�f/� 1d7,F iYY
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Name od-p-x/ 5d ��f5 Case #
Date of Cremat i cn
Time Cremation Started r
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Time Cremation Completed 191m,
Type of Container
Remarks :
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ATTACH ACUMORIZATION 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 and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of AZ.,E)�:/�5C N. Lk, /ti (hereinafter referred to as the"Deceased,,).
Name of Deceased
Date of Death '7 c 1^ Time of Death 2:3:�;- ❑AM. ,®P.M.
I/We hereby request and authorize 61 J 5(�A i f 4- E,4.,V y/ (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
take possession of and maize arrangements for the cremation of the remains of the Deceased at 1014 7-ill t:V kj t�%14%-,Zy
(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
erstand
ions
rematory
are
thedpossession that
custody of the Fluneral Home.f I/We hereby shall authorize fulfilled
om t en the ted remains ar arrange for the disppositiondof the urned crematedto
remains of the Deceased as follows:
Is special handling required? ❑Yes ® No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to
Cemetery
Name and Address of Cemetery
® Release to family :_1,,I S
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 crem. , a disposition and d edthf shall b n ance with all
governing laws, e ruls, gulations and polics of the Crematory and Funeral Home,and e following terms 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 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
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
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. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT EKI 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 he 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 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 the cremated remains of the Deceased and disposed of by the Crematory.
remove from the cremation
5 not limited hereby authorize
the
latches,nails,jewehy separate
and precaous metals and to dispose of suchl materials.
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.
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 S days• a week
7 :00 A. M. — 3 : 30 P. M. Monday—Friday. No ' Flo idays 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. CasItets , and containers must be of combustible
r; mat'eri)al:�' 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
acc,ep't e'd.
b•1'-' " Unles•s 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 S20, 00
char..ge. .for,- this service,
Cremation, Administration Costs and Recording Fee : -Adult $ 105. 00
Chj_ldre_n_,,_,(age._ 13 months to 12 years ) tl ]•0. 00 Infants ( st i 1 lborn
to 12= month's ) +yf�0. 00
TOWN OF ❑UEENSDURY
13INE VIEW CEMETERY
A
CREMATORIUM _
Quaker Road, Queensbury, New York 12804
Phone (518) CrIematorium 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)
2 Co Q T�k Q LrS ��AJL 1111,L, R 6. J,Ak6 C9 LaG&� Al-
(Street ) - (City ) (State) ( Zip Code )
who died on day of 19�
(Place) (Address)
Name: and . add ress of nearest living relative or name of per-sori
autho.ri.z . ngcremation :
'(Name) (Address )
Relationship ,to the deceased
Name of Funeral Home PCaWJ + bLA(&
IMPORTANT
" I''represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I' cert:i'fy``that I have the full power and -aut:horization to arrange
for' the'' cremation of the remains and to direct the disposition of
the' crex`alt`ed remains, that any personal possessions have either
been removed or may be , destroyed, and agree to protect, defend
and s'aveMharmless ' Pine View Crematorium from any and all claims
and'`'dem'and'st,'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
groundIes`s;``*fa1s'e or fraudulent.
(Witness ) (Address )
. :rry�" 5D
al • .
(Signature of Relative or Legal Rep. and Address)
Signed on this date : _ _ J��y y?9-r