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Scheis, Bonnie T07+N OF QUEEVBU_' � PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director � JV D'— Name Case # Date of Crematicn4""'Z ( / f � Time Cremation Started 1 �r- Time Cremation Completed&, �� 1 Type of Container Remarks : AM i 14 at)IrA-i? 0,4 11.0 14-16 L/,6_r0 12 /;Zo r9 /M r /1 �� /� .•'3�.�} ,ivy, Z/. d9 d"M 1 i i i TOWN OF QUEENS©URY • PINE VIEW CEMETERY —f-.J34�L— A CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) CrIeinatorium 745-447'7 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 ) (State) ( Zip Code ) n /\$� ' l 9 %L who died on �LJ day of -1-' at P (Place) (Address ) Neime; and . address of nearest living relative or name of person authorizing cremation : (Name) (Address ) Relationship to the dec se Y Nance 'of Funeral Home ` IMPORTANT: sent that to the best of my knowledge, the deceased has or ( has no acemaker in his or her body. (Circle One) I cert:i'fy ' that I have the full power and -authorization to arrange "for' th`e' cr'ematfon of the remains and to direct the disposition of the' cre'm�atre;d "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'``dema'nds ;'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 groundl'es's';'!'faIs'e" or fraudulent . M ness ) (Address ) ea&2�AaUL 1, -Y-. Signat a of Rel tiVe or Legal Rep. a Addre s) 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' axnd 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 eaddition 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 cumbustible '^a tIer'i:a,I', .No styraFoam or plastic_ containers wi11 be accepted. 5.',s The 'que,stion relative to cardiac pacemakers must be answered on must cremate form before the remains will be ' accept ed. ''" 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 s20. 00 charge—for- this service. Cremation, Administration Costs and Recording Fee : •Adult $ 1a5. 00 Ch,i_ldre.n,_•___(age._ 13 months to 12 years ) s11,0. 00 Infants ( stillborn to !2 month's )',.ti`j0. 00 ZAUTHORIZATION FOR CREMATION AND DISPOSITION - CE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING ned,ce ,warant and represent that I/wehave the full legal right and authority to authorizethe cremation,processing and premains of 613ji+ t' ,r :fi (hereinafter referred to as the Deceased"). Name-of ec Date of Death A�-i ,/, ,t/�'Irene of Death ❑AM. ❑PM. I/We hereby request and authorize ' '(c- 11 y d 1 (hereinafter referred to as the"Funeral Home)to Name of FUrei4d Home take possession of and make arrangements for the cremation of the remains of the Deceased at '^;•;U - t U (hereinafter referred to as the"Crematory"). ^0 Name ofCCrematory �— I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we undet the the shall be RM' d when the ed ains are to thepossessiond n and and custodys and of the Funeral al Hogations fine. I/We hereby authorize thheeFune al Home totarrangem for the dispositiondof the cremeadted P Y Y 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 [)i Release to family j' 1 e ( } 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 remains of Deceased ein shall he ed in accordance governing lalws,/Je rulesrocess, g and disposition of regulations and policies of the Crematoryyand Funeral Home,yandyth following i s and conditions:: with all 1. 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 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 male 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 tyype of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we herehy authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and disp , f such items at its discretion. LVE 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 implaan"fed 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 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. me 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 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 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. R T„ +11P P,IP 4 +11P „rr, — ;a ;n—M,;... +„ ...— J.+P all -f A. —.+P,l f A. f • ATTAC,'1HT TH "AUORIZATION FOR CREMATION AND DISPOSITION BOOKI w;-+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,he undersigned, certify,warp.nt and resent that I/we have tliefull legal right and authority to authorize the cremation,processing and disposition of he remains of i v U r` `:>L 14, _FS (hereinafter referred to as he"Deceased"). Name of Deceased Date of Death 1114k., IU %'`- Z'Trine of Death ❑A.M. ❑P.M. I/We hereby request and authorize r.f. ��/tl = -,)/-"r-y$&,, (hereinafter referred to as the"Funeral Home")to Name of Funeral Home take possession of and make arrangements for the cremation of the remains of the Deceased at ;'`7,V/ ✓.a c i.J % "_ ,L%-+l (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 custody of the Funeral Home.rned to unde nd t the s and the Cremato shall e fulfM- d when the cremated ains the are thepossessionaand custody of the Fluneral Hogations mme. I/We he eb au hbrize the FuneralHome to arrange for t{he disposition dof the cremated P Y Y g 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 an Address of Cemetery Q Release to family o iI!:'S 1 I t ''� ',l } 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, processing 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 he 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 he removed prior to cremation and placed in a combustible cremation container I/We further authorize he 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 implanted 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 andiemploye#s,Lto remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose,of such items at its discretion. L E HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOTONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. L�� 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 be disposed of at he 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 fume. 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. I/We herebyauthorize 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 urn or other containeL 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.r .1 1 .1 -- - ------ -- L_ __..�_........,.,l.,�e -11 „f 4-L- +o.l .P,,,a,,,a 4 4-bP DPrPaQP.A- arnv excess cremated