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Creswell, Alpheus To%N of QUEErN4,5BU9?1Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director N a m e //-i7)yj5 Gfr,E��, �� C a s e #i Date of Crematicn !t— Time Cremation Started /zz f r t Time Cremation Completed // o?1oZ L / 1�' n Type of Container M)9/V c15;,—e Remarks : /C7- ATTACH AR59 N FOR CREMATION AND DIQSPONS �SNTION CfRNIN CREMATION. BOOKLET HERE NQ'17ICE:TIAS IST. IT CONTAINS IMPORTANT PR CREMATION IS IFINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING processing and ce , that I/we have the full legal right and authority to authorize the cremation, I/We,the undersigned, hereinafter referred to as the"Dec )• ;t'LC-`disposition of the remains o Name o Decease Time of Death El AM. ❑PM. Date of Death ! `�7 "Dupers(hereinafter referred to as the 1 Home")to � I/We hereby request and authorize Q&C.A►� `t" Name of Funeral Home +�/,�C L~ 9l�( ',1•'(-�''lA r Y take possession of and maize arrangements for the cremation of the remains of the Deceased at Name o Crematory (hereinafter referred to as the"Crematory") Home. I/we I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funerals returned to understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains o}the Deceased the undeposrstand that 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? El Yes No Describe Suitable for shipping: ©Yes ❑No Description of urn or container selected: L3 1Lt Cemetery ® Deliver to ti' ' 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 T Address: o: Name: ❑ Other F'- StateesPb�sbZal Fun e andCrematory are not responsible for any loss or damageof cremated remains shipped via Registered Mail with the UnitedService. ion, rocessing and disposition of the remains of the D The cremation, eceased authorized herein shall he performed in accordance with all and policies of the Crematory and Funeral Home, and the following terms and conditions governing laws,the rules, regulations : 1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leap resistant, rigid ornaments and an other noncombustible items cremation container. The Crematory is authorized to remove and di ep2o�aema handles,the Deceased are received by the Crematory in a casket attached to the cremation container prior to cremation. In the event tlr or other container constructed of metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to he 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- rd eased Mechanical or radioactive devices implanted in the remains of the Deceased (suchhumanaremanaswhich contain any? etc.) may create atypeaof when placed in the cremation chamber. The Crematory will not cremate any contain such a device, Iny hereby implanted mechanical or radioactive device. In the event the remains of the Deceased a remains of the Deceased authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from th prior to cremation, and dispose of such items at its discretion. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT [—y-� 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 o�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 he 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. bridgework, 4. Certain items, including, but not limited to, body prostheses, dentures, dentaldental 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. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not limited to,hinges,latches, 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 be mechanically pulverized to an unidentifiable consistency prior to placement in an um 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 T 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 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 -ind 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 Recording Fee : Adult $ 105. 00 Children (age 13 months to 12 years ) S1 ],0. 00 Infants ( stillborn to 12 months ) f70. 00 TOWN OF ❑UEENSDURY PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Uueensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHO111znTION 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 ) (Stag (Zip Code ) who died on ao day of1- 19C_ at l��L/�1S I�A,��.S f�1cSl�t 1 A�.. (Place ) (Address ) Name and address of nearest living relative or name of Person authorizing cremation : J014 Y 4._15 L a2 /2 l 50 Cnti�S �a!a3n,— /\J• Y, (Name) (Address ) Relationship to the deceased Ney,I Nave of Funeral Home 0,"A61 `F LZY2i/_— 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 certify that I have the full power and aut.horization 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 or damages which may be made against them by reason of or connected with the cremation of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent . (Witness ) (Address ) r (Signature of Relative or Legal Rep. and Address) Signed on this date : AL)GU51