Clymer, Martha "OWN OF QUEEVBU_'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director c �70-A -- 9, 91
Name Case # 33
Date of Cremation " /4 —y /
Time Cremation Started
Time Cremation Completed
Type of Container Gr�I�Q o191FD 3 /Tpi
Remarks :
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TOW bI UtJtENSeUhY
pINE VIEW CEMETERY
CREMATUOIUM
ovaker Road, Queensbury, New York 12904
Phone (51g) Crematorium 745-4477C,or if no answer
Cemetery
AUTHURIZptIUN TO thEMATE
The undersigned requests
et to its Rles and Regulation
acauoeS ine u View s to
in
accordance with and
cremate the remains of:
"a,
(Name) (Sex)
(Street )
(City) (State) (Zip Code)
who died on
day of 19�
at (Address)
(Place)
Name and address of nearest , living relative or naM6 of person
authorizing cremation :
0011
tNam ) (Address)
Relationship to the deCeaeed
—LaV9,Z,
Name of Funeral Home
IMPURTf1NT: khowledge, the decoAsed has or
I represent that to the Best of my 6 (Circle dne)
Gas n
pacemaker in his or tier body.
I certify that I have the full 'power and authol-1 iat i bh to
arranon ge j
for the cremation of the remains a to ersonaldipossessionsrect the shave either
the cremated remains, that any p
been removed or may be destroyed, and agree to protect, defend
any and
and save1fiarforslo�ssrror dama►gesewhichimayfbemmade againstlthemiby
ms
and demar ds
reason of on connected with the cremation of said remains as
or are not wholly
directed, whether such claims or demands are
groundless, f Ise or fraudulent.
(W tness) (Ad ess) ,
(Signet f
e of ReIJ ive or Legal Rep. and Address)
r ��
Signed on this date : ���' 7
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, Ouaker Road, Town of Oueensbury.
3. An authorization for cremation properly signed by the nearest
nett 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 Recording Fees -Adult $1135. 00
Children (age 13 months to 12 years) f11,0. 00 Infants ( stillborn
to 12 months) f`70. 00
ZOOKLET
AUTHORIZATION FOR CREMATION AND DISPOSITION-..-.
CE;T S"fS- EGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
ned, ceraf,wa t and rent t I/we a full legal right and authority to authorize the cremation, processing and
spsonoeremains of (hereinafter referred to the"Deceased").
Name o ea �
Date of Death g 1>C✓5 7 Time of Death ❑A.M. ❑PM.
I/We hereby request and authorize. , � — j -p -� (hereinafter referred to as the"Funeral Home")to
Name of Funeral Holne '}
take possession of and"arrangements for the cremation of the remains of the Deceased atd.�7 -a
(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. I/we
Crematory
he
to
understand
de ewe that
custodys and of the Fluneral Hoions me.e.e.eI/We hereby shall the
when Home oted remains of arrange for thet dispositiond are of the crmt cremated
P Y Y
remains of the Deceased as follows: �,/�
Is special handling required? El Yes 1/J No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
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*
To: Name: Address:
❑ other
neral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United
Postal Servi
[-�—tstatesce.
The
disposition of the remains of
rein
governing laws,/ e ndes, a regulations
ionss and policies of the Crematory yand Funedral Home,yand the followings b performed
and conditions:
with all
i- ..a remains ofltlie 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 rioncumbustible 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
in when placed in the cremation cha er. 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 erehy
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. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT &:7—] 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 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
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. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not limited to,binges,latches,nails,jewehy and precious metals,and to dispose of such materials.
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will he 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.
n T_ L_ ._--.L ,.L.. ...... -- ,.,,-4 ..... ;a ,,,e,.if; ;o.,+ + all of tl,P oremated remains of the Deceased. anv excess cremated