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Maille, Marion '7nTVN OF QUEEVBU9U PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name ---==R 1 (94 -Case Date of Cremation " — �� Time Cremation Started Time Cremation Completed Type of Container Laf?rf&A)W _]7XL), eA E [j/="�/7/�C- �,,�"� Remarks : (t.,2 r9 1/) An 1 ll /;Z%g9 Am 1 TOWN OF QUEENSDURY �� .✓�/�i PINE VIEW CEMETERY CREMATORIUM Quaker Road, Uueensbury, New York 12804 Phone (516) Cr'e'inatorium 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 ) (Street ) (City ) (State/jj� � ( Zip Code ) who died on day ofAti (Xs..� 19 at (Place) (Address) Naime, and_ address of nearest living relative or name of person autho.ri1zing cremation : Al . (Name) (Address ) Relationship .to the deceased Name 'o'f Funeral Home ` IMPORTANT e t that 'to the best of my knowledge, the deceased has or has no pemalcer in his or her body. (Circle One) 'I' certify` that I have the full power and -aut:horization to arrange for' th"e'" crenrati'on of the remains and to direct the disposition of the' crew`atted ` remains, that any personal possessions have either been removed or may be . destroyed, and agree to protect, defend "and save harml'ess' Pine View Crematorium from any and all claims and' demands�i•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 groan les's',' '-false r f'r ulent. ( itness) (A ress ) (Signature of Relative or Legal Rep. and Address) Signed on this date : oZ-� `� DISPOS1TiON 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. ti. All remains must be encased in . a cast<et or suitable alternate container. Caskets and containers must be of combustible material.`' . . styrafoam or plastic_ containers will be accepted. The question relative to cardiac pacemakers must be answered on- .. ... I ..T'auti zat ion to cremate form before the remains wi l l be 6nless 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. Thery will be a t2i), 00 charge-for- this service. Cremation, Administration Costs and Recording Fee : •Adult t1p5. 00 Ch,ildren (age.. 13 months to 12 years ) ti ],0. 00 Infants ( stillborn to 12 month's )`.:,'s`10. 00 Zli'ERNOTICE AUTHORIZATION FOR CREMATION AND DISPOSITION [�U��ITH� A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. REVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING ned, certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and sposonote remains of f`i,V` ,Al L tiaT L (hereinafter referred to as the"Deceased"). Name of Deceas Date of Death '3 t;-) Time of Death (> []AM.. Y PM. I/We hereby request and authorize-l &-AA/,- 9 /�//�/� (hereinafter referred to as the "Funeral Home")to Name of Funeral Home take possession of and mare arrangements for the cremation of the remains of the Deceased at ";r ,J (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 understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the 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 X No Describe Description of urn or container selected: f (%( ( ,� jQ / Uf O vij( i U'-C r" Suitable for shipping: ❑No ❑ Deliver to pp g Yes Cemetery Name and�d�ress of emetery Release to family i.�J 1((. /`l"� f[ ('1` i (A Name of Desi ted Family Me er 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 rocessi isposition of e remains of the authorized herein shall governing laws,/t e rules, regulations egult idons and policies lof the Crematory and Funedral Home, and the follow bg terms and conditions: ormed in accordance with all 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leaf 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 make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2 Mechanical e haiplaced in the radioactive devices ehambimplanted inCrematorythe rains of the Deceased (such as pacemakers, etc.) may create a hazard 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. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 0 DO NOT WW--] 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 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 he separated from the cremated remains of the Deceased and disposed of by the Crematory. 6 noehmit d touhinges,thorize latches, nails,jewelry separate and precious metals and to dispose of sm the cremation luch materials.mber noncombustible materials including, but 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiahle 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.