Delaire, Shirley TO%N" OF QUEE1VBU9?1Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S!
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Date of Crematicn�_
Time Cremation Started
Time Cremation Completed
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TtbWN bE OUEENSBUhY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12904
Phone (518) Crematorium 774-4477�or if no answer
Cemetery
AUTHORIZRtiOW TO CREMATE
The undersigned requests and autoaitseS ine Rules View and Regulations to
in
accordance with and subject
crema a the remains of:
a-vy�
(Name (Sex)
(Str t ) (City) (Scat ) (Zip Code)
who died on
day of 1992
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
i
(Name) (Address) j
Relationship to the deceased
Name of Funeral Ham
IMPORTANT: knowledge, the deceased has or
I r�nr
t that to thebest bf my 9 +haso pacemak in his or her body. (Circle bne)
I certify that I have the full 'power and aut hoi^iiatibn to arrange
for the cremation of the at any ersonal direct
possessions disposition
either
the cremated remains, that any p rotect defend
been removed or may be destroyed, and agree to protect,
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
s as
with
in
reason whethernsuchdclaims ore demandsoareoorsaare noawholly
directed,,
groundless, fa se or fraudulent. j
(Wit ess)
( ddress)
(Signature of Relative or Legal Rep. and Address)
I
Signed on this dates
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 Uueensbury.
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.
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.
5. 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, ' Administration Costs and Recording Fee: •Adult $185. 00
Children (age 13 months to 12 years) $ 11,0. 00 Infants ( stillborn
to 12 months) fy0. 00
t
AUTHORIZATION FOR CREMATION AND DISPOSLUM
NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
undersigned,cer�,warrant d xe nt tha I/we have W legal right and authority to authorize the creation,processing and
isposition of the remains of ' Gr 4 f G (hereinafter re&.v to as the"Deceased,').
Name of Deceased
JDate of Dpatb2"-, 14f7 Time of Death eA.M. ❑PM.
I/We hereby request and authorize (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
take possession of and make arrangements for the creation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the created remains of the Deceased to the possession and custod of the Funeral Home. I/we
undetions
Crematory
be
when the
ed remains o e Deceased are
d to
the possesssionn and custody of the Fnd that the services and uneral Home.e%We hereby h authorize Funs al Home totar arrange for the disposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes eNo Describe
Description of urn or container selected: suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
❑ Release to family
Name of Designated Family Member to Receive Cremated Remains
El 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 he performed in accordance with all
governing laws,the 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 creation 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 noncumbustihle 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 chambei% 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. 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 implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased j
prior to cremation,and dispose of as indicated:
I
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 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 he separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We�rtebyed�u��s,latches,e the nails,Cremat to ory
and precious arate metalsremove ,and to dispose of em the cremation lucmaterials.
all
noncombustible materials, including, but
not 6. Following creation, 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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