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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! t T Name � � �� ,1�� ,L _Case # Date of Crematicn�_ Time Cremation Started Time Cremation Completed Type of Container Gz9�eDI3o /\�� 1�rG 7 Y Remarks : I 01g J13- All 1 l I z r' hE8` l i i I a, 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. �.-:;� �- �� �--�-._._a--