Messier, Mary TORN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C6—'dl PC -aewlyy
Name M Case #
3s�9
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
, .. CREMATORIUM
3�
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-447'7 or if no answer
Cemetery 745-4476
AUTHOli I zAT I ON 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 :
(Nam — - (Sex)
r1 I`�1Aint cal )q01- ynf /=,Arl./.S A! /d'ts'32
(Street ) - (City ) (State)T ( Zip Code)
who died on 125 day of AUG OSi 1937
at �k,
(Place) (Address)
y Name. and . address of nearest living relative or name of person
authorizing cremation :
„lU� (c ��1. ]��t�SSir✓l2- 13c� G] NAB C26P-0/1/660 S�rrrJrc�Go C�.
,(Name) (Address )
Relationship .to the deceased
Name `of Funeral Home li LGAA1 °+' bLN/Jy
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' c4rt'ify'`Ithat I have the full power and -aut;horization to arrange
for the ' crematfon of the remains and to direct the disposition of
the* crem�at'ed remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
,and s har ave mless ' Pine View Crematorium from any and all claims
and' Vemand'st"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
groundless; false or 'fraudulent .
2, WA22LAi5 434)PC
( it ess) (Address )
ZI)
( ignature R latiVe or Legal Rep. and Address)
Signed on this date : -060 -' 0-1-5 � �5
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 S 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 C r e rr.a t o r i um 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, -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 casket or suitable alternate
container. Caskets and containers must be of combustible
material" ' No styrafoam or
It o•r,r plastic containers will be accepted.
. 4,
: The 'question relative to card4ac pacemakers must be answered
o.4 ` .. he "auth`orization to cremate form
accept ed. ; before the remains will be
...
r r. v, r1
" Unless other arrangements are made the cremated remains will
be mailed -via Registered U. S. Marl within three days of cremation
to the funeral home handling the service. There will be a L20, (�0
charge—for- this service,
Cremation, Administration Costs and Recording Fee :Ch,i.l,dre.n.,.:_ (age._ 13 Adult >; 1p5. 00
months to 12 years ) t11,0. 00 Infants ( stillborn
to o 12= month's")'•.5"t`j0, 0p
ACHBOOK*E •AUTHORIZATION FOR CREMATION AND DISPOSITION s+r1•
RE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
VW,,the undersigned, ,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of M t�l O j'rl t - /t,4 (hereinafter referred to as the"Deceased").
ame of Deceased
Date of Death �r f -- 97 Tune of Death ❑A.M. ❑P.M.
I/We hereby request and authorize I26-GA + PCAW Y (hereinafter referred to as the"Funeral Home")to
Name o Funer ome _
take possession of and maize arrangements for the cremation of the remains of the Deceased at 1 1n1 V&: YV c i" /,1/4 Lk
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the cremated remaiinns of the Deceased to the possession and custodyof the Funeral Home. I/we
understand t the services and
ions of
be
ed
en the
remains of the
are
to
the possession and custody of the Fluneral Homte the Crematory
hereby�authorize Funeral om to as ange for the disposition dof 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
21 Deliver to L'Al!oN C t= �►i:;i Gl�.Y Ft-I'—"r t5(Z)YVAlZZ� Y 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. t
The a / disposition
a remains of the Deceased
authorized herein b P accordance with all
sguliOnsandpolgove e rule of
of the Crematoryand Funeral Home, and following s 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 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
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
im lanted 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 = DO NOT ® CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Dome 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 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 be separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We�rtebytoaut��s,latches, nailse the ,jewelry and precious metals and to dispos to separate and remove from the e of suon hematerials.
all
noncombustible materials, including, but
not 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.
�, r .1 . .i '--- --- -- 'z-__fL_.__L i_ _ l are -11 4- -f 4-L.- .,....A anv Pxwoss cremated