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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 A7 1 Al 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