Kennedy, Anna T07+N OF QUEEVBU. Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i
Funeral Director 51
Name ���ltdJX Case #
Date of Cremation
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Time Cremation Started /5-0-L I7 /"
Time Cremation Completed `A lf,2 0Z- 19f
Type of Container 54�ri)ijo 7 91YP/ ! & E
Remarks :
/l7a�, 0 l i(cJ A/M
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TOWN Ut UUtENSBUhY
pINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetef^y 745-4476
AU tHUR I Z01UN TO l:UEMATE
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)
-3 ( p Co
(Street ) (City) (State)
day of At6ogr- 19
who died on gzw S F�/NV--
at L7//( rf(Place) Address)
Name and address of nearest living relative or nape of person
authorizing cremation: _
AAR
8 R ,o
V� a e) (Address)
�. .
Relationship to the deceaeed
Name of Funeral Home
IMpURTANT: knowledge
the decbAsed as or
I represent that to the best of my g +
has no pacemaker in his or her body. (Circle dne)
I certify that I have the full 'power and authoi^iiatibn to arrange
ion of
for the cremation of the remains ersonal to di possessions rect the shave teither
the cremated remains, that any p
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Ct-ematorium 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
or demands are or are not wholly
directed, whether such claims
g oundles , fal e o f udulent. 'A h &A D1 . 6-)(al
C '
(Witness) (Address
A))
( gnature of Relative or Legal Rep.
and Address)
Sinned on this dates
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 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 clays of cremation
to the funeral tome handling the service. There will be a $20. 00
charge for this service.
Cremation, ' Admin: stration Costs and Recording Fees -Adult f105. 00
Children (age 13 months to 12 years) ill:0. 00 Infants ( stillborn
to 12 months) $'70. 00
f
f {
S 3
ATTACH ` AV THORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTI THIS IS A LEGAL DOCUMENT'. IT CONTAINS IMPORTANT PROVISIONS CONC*RNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned,cert y, t qd represent that I/we a full legal right and authority to authorize the cremation processing and
disposition of the remains of F' (' (hereinafter referred to as the"Deceased").
Nameo D
' Date of Death
Time of Death ,�✓J �!n A.M. ❑P.M.
I/We hereby request and authorize 7 ` r-; , - (hereinp�r referred to as the"Funeral Home")to
Name of Funs me
take possession of and male arrangements for the cremation of the remains of the Deceased at 1 �► q
hereinafter referred to as the"Crematory"). Name 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
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains ofythe 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 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
* 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, rocessing and disposition of the remains of the Deceased authorized herein shall he performed in accordance with all
governing laws, e 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 noneumbustible 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
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 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 DO NOT 0 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
lease 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 ibspremation,and �pose as indicated: /� s
Description of Implanted Device Disposition I
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 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 remain,of the Deceased and disposed of by the Crematory.
5. I/We hereh authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not limitedyt0,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.
-1 . .1 . . . . rr. . . . i . 11 r .i 1 r .i 1 i
"Customer's Designation of Intentions"
Name of Deceased: A)N r P-)
Cremation: �7- z
(scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
C� Burial at A36 I-,-)A 0 0 kA b64M, El Retu' rn to Family
El Entombment at 0 Other (specify):
i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
.Itl
(Weplum.Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may he disposed of by this firm by pl�me t in a c+mbarium."
r
Printed Name of Funeral Director Signature of Funeral Due 92 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:Fimeral Home Copy YELLOW:Family Copy PM:Crematory Co" CUSINTEN Rev.4/96