Brickner, Milton ,rnWN oF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
-ga4ay aLaEyd )(
Name /�. �C3/� /�/C�/v � Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed D 3d M
Type of Container
Remarks :
All
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Il Il ;C?r"g,t4
TOWN bt oUE!_Ns80hY
PINE VIEW CEMETERY
CREMATURIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetef^y 745-4476
AUtHURIZgt1UN TU (AEMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
i I- �r t c-VANr
'n (Name) ,� ^) (Sem)
(Street )+ (City) ) (S ate) (Zip Code)
?r
who died on ZJ day of
a t
(Place) (Address)
Name and address of nearest living relative or naMO of person
authorizing cremation:
It,kyl U-
(Name) (Address)
Relationship to the deceased -
Name of Funeral Home ^
I MPURTFINT:
resent that to the best of my khoWledge, the dectAsed has or
gas n pacemaker in his or her body. (Circle dne)
I certify that I have the full 'power and authoi^iiatibn to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possession's 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 or damages which may be made against them by
reason of on connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address)
tSignature of Relative or Legal Rep. and Address)
Qlnned 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: C
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND nEGULATIONS
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 fai, 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 agaitist 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.
S. 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, ' Admin: stration Costs and Recording Fee : •Adult $1135. 00
Children (age 13 months to 12 years) tilp. 00 Infants ( stillborn
to 12 months) $` 0. 00
H
BOOKLET
AUTHORIZATION FOR CREMATION AND DISPOSITIORi
BOOKLET �
HERE NOTI TI�IS'IS AILEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
R CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
diI/We, the undersigned, ce t represe that we have the full legal right and authority to authorize the cremation,processing and.
sposition of the remains o} 1 y� f 1 L. (hereinafter referred to as the"Dec
Name o Dec eased )
ate of D 62199 Tnne of Death �V•,`S -kkm. ❑pm.
I/We hereby request and authorize tl C", T J 1 .r (hereinafter referred to as the `Funeral Home")to
Name o Fune Home
tape possession of and make arrangements for the cremation of U remains of the Deceased at `• I i 11-'
(hereinafter referred to as the"Crematory"). ` " LA`i
er re Name Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Homer/we
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to
f 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 �KNo Describe
Description of urn or container�ected* Suitable for shipping: ❑Yes ❑NoDeliver to �'-"�l l E f lJ, Qtil l~ ,r .i,.t t Cemetery
Name and s 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 be performed in accordance with all
governing laws,de 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, f 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 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, an dispo of such items at its discretion. 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 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 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,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 he mechanically pulverized to
an unidentifiable consistency.prior to placement in an urn or other container.
7.'-Mess 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 desioned for anv tune of shipment_
'I;
BOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITIOI+�,I
BOOKL
HERE NOS ThE4,Ii.AALEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
dI/We,the undersigned,a ,warrant and represent_that I/we have the�ull legal right and authority to authorize th
isposition of the remainr of a cremation,processing and
Name o�ec (hereinafter refereed to as the"Deceased").
Date of Death ' Time of Death�� �`). i�A.M. ❑PM.
I/We hereby request and authorize r (hereinafter referred to as the"Funeral Home")to
ame oT e—raVFome - t
take possession of and make arrangements for the cremation of th remains of the Deceased at r y`
(hereinafter referred to as the"Crematory"). Name o Crematory
I/We authorize the Crematory to return the cremated f the Deceased to the
remains o e e possession and custody of the Funeral Ho . 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? ❑Yea No Describe
Description of urn or container selected. Suitable for shipping: ❑Yes ❑No
EJ(Deliver to Cemetery
ame and s oemetery
❑ 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, 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:
I. 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 noncombustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container Me 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 1m{�1 nted in the remains of the Deceased (such as pacemakers etc.) may create a hazard
When place in the cremation chamber.
d 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 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all imp hanical 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
Seseription of Implanted Devine 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
itrevewibly 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 accompanyin 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 sep}a'rated from the cremated remains of the Deceased and disposed of by the Crematory.
to
5 noehmit d to,lthorize the hinges,latches,Crematory
jewehypand precious metals,and to disposte and remove from the eion e of chamber h a noncombustible materials, including, but
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.
8. In the event the urn or enntainPr is inanfFin9Pn+ +n annnmmrvla+a all 4 A. ,nma+o l ------J