Melanson, Frances r-
z0qlVN OF QUEEVBU-9?fY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case 1!
Date of Cremation l
Time Cremation Started b f dd' m
Time Cremation Completed 66'6 /mf
Type of Container _ .,Aq.Md"
Remarks :
Al d l N d&)IViVA'R
JAI ZeE]2
1 - d t M '
TOWN OF QUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (518) Crematorium 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 :
i:�/?-A.Ne15-S IVI&k A N Sa 14 _..
(Name) (Sex )
(Street ) (City) (STate) ( Zip Code )
who died on 120 fN day of /gU�U51 19
at �.. L`--NS �' S..S 110501 A L
(Place) (Address)
Nam,e: antd:. addre5s of nearest living relative or name of person
autho,ri,zing .cremation :
3 Z5CCA LE PAC 1L 39(0 (�,Ac,L �(R Ad i 12 b. a JOCI l=)n(c4b, i\0.
,(Name,) (Address )
Relat i`onship .to the deceased A/)G [AI(5C
Name off Funeral Home_ i2r('- XA1 A bEldN f
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' ce,rt`i`"fy'°`that I have the full power and •aut:horization to arrange
for' th'e'' crernation of the remains and to direct the disposition of
the' crem�atred "remains, that any personal possessions have either
been removed or may be , destroyed, and agree to protect , defend
), � ,,.,•q, ,..:,... , . ,
and save harmless' Pine View Crematorium from any and all claims
" and'`Vemand's�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
groundless `''faIs'e'' or 'fraudulent .
(Witness ) (Address )
(Signature of Re tiye or Leg6il Rep. and Address)
Signed on this date : AL)C'AL)S ( aSa k952
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 crenated 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.
•. ., All remains must be encased in , a casket or suitable alternate
cont;ailner. Caskets . and containers must be of combustible
material.' No styrafoam or plastic. containers will be accepted.
material-
, . .
5• ' iThe qu.e,stion relative to cardiac pacemakers must be answered
on`' the"'auth`orization to cremate form before the remains will be
F accepted, `r; ...;
6.f' � UnIes's 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 ic'0, 00
charge.•.for- th i s service.
Cremation, Administration Costs and Recording Fee' : .Adult tl£35. 00
Ch,i.ldre.n.,_,_.(age,_ 13 months to 12 years ) s13.0. 00 Infants ( stillborn
to 12, month�s )S'+ t70. 00
Z
AUTHORIZATION FOR CREMATION AND DISPO 014
'0
CE:THIS S A LEGAL DOCUMENT. IT CONTAINS IMPORTANT'PROVISIONS CONCE CREMATION.ATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
igned, ,warrant antiip t'that I/vx4ww -"v cessing and
p remains o r=/2-A 4 C JL.' j j_a A ,l 5 0,.! —(hereinafter rJto as a"Deceased").
Name-of Deceased
Date of Death Time of Death ❑A ii ❑P.M.
I/We hereby request and authorize a L Cl A t4 •t- D E N d X (hereinafter referred to as the"Funeraj-Home")to
Name of Funeral Home `
take possession of and make arrangements for the cremation of the remains of the Deceased at et tJ c yit:IiV ,- 67"Jo 1 9,y
(hereinafter referred to as the"Crematory"). Name of Crematory T
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we
t the
he Cremato hall he
en the cremated
ins of the
are
to
thedprstand o a sssionaand custodys and of the Fluneral Hogations me.e. I/We here aautthooriz�leFuhera Home to arrange for the disposition f the crmt cremated
P Y Y g P
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: JY%a o 131L^PJ Suitable for shipping: kles ❑No
R Deliver to—Vttq ri /7,T44=J� - 0-,(Ni t=Z- U 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: r'
❑ other 3
* Funeral Home and Crematory are not responsible for any loss or damage of cremated remains sped via Registered Mail with the United
States Postal Service.
The cremation, roeessing 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, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to he
removed prior to cremation and placed in a combustible cremation containeL 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
aut�orize 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 F—� 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 in*nse beat,and direct flame. I/We authorize the Crematory to open the cremation.chamber
during the cremation process and reposition the remains of the beceased 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.
5 �lirnitedyto,authorize
hinges,latches,nails,jewel to ry and precious
arate t remove metals,and to cremation
dispose of such materials.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.
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