Seagle, John 7owN of QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name '1() zzid iC Case #
Dat a of Cremat i cn
T
Time Cremation Started &110 4 /N1 k
Time Cremation Completed ���t � /M
Type of Container ��/� D��/7/l gAlp,
Remarks :
1476 L467_0 426M
13 ,19141 ,
i
TOWN UE ULEEHSSUhY
PINE VIEW CEMETEhY
CREMATOR I UM
Quaker Road, Queensbury, New York 12804
Phone (519) Crematorium 745-4477 or if no answer
Cemetei^y 745-4475
AUtHURIZAt1UH TU UEMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft
(Name)
(Sex)
'Izz- e 1,2-9- -2 z.9
(City) (Sta e) (Zip Code)
(Street )
who died on
d2 .Z d ay of � z- 19�.2.
—
9e,
at (Address)
(Place)
Name and address of nearest living relative or nam6 of person k ,�
authorizing cremation:
Name) (Address)
Relationship to the defeated '
Name of Funeral Home
IMPURTANTe khowledge, the dectAsed has or
I rep��O:
g�hat to the best of my
has pacemakae in his r here r une)
,� the 1power and a�lthoi^i iat itfn to arrange
I certify that I have tdisposition
for the cremation Of the remains ndtldippossessiorect the s have either
the cremated remains, that any persona
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 or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
i no ) (Rddress)
/ ,J
oZ
(Signature of Rel ive or Legal Rep. and Address)
Signed
ed 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. Pins View Crematorium is located on the grounds of the Pine
View Cemetery, Uuaker 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 Fees •Adult $105. 00
Children (age 13 months to 12 years) t11;0. 00 Infants ( stillborn
to 12 months) $'70. 00
X
---"AUTHORIZATION FOR CREMATIONAND DISPOSITIQN
CE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
ned, cer*,wanan ar represent tha I/we have he full le al right and authority to authorize he creation,processing ad
sposonoeremains o o d 1 1 e a �C (hereinafter rekTred to as the"Deceased").
Name of Deceased'
Date of Death L 'rime of Death ❑A.M. ❑P.M.
I/We hereby request and authorize ti fL-a. I (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home (� /
tape possession of and make arrangements for the creation of the remains of the Deceased at ID,I 1 C 4" -C- " 6- Ac' Idol
�r 1ci✓e✓�U
(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
erstand
gations
cre
are
to
the dpossession
oss ssithat
and custodservices
of the Fuuneral Home.f I/We he eb au hooriz Funeral ome to cremated
arrangefor the dispositiondof the returned cremated
remains of the Deceased s follows: yg P
Is special handling required? ❑Yes ❑ No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ' ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
El 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 created remains shipped via.Registered Mail with the United
States Postal Service.
The
rocessing and
ispsition of the remains of th
perfored in
governing lalws,,de rules regula ansoand policies of the Crem toryyand Funeral Home,authorized
andherein
he following shall
g i s and.conditions:
with all
1. The remains of the Deceased will not be accepted for creation unless received by the Crematory in a combustible, leaf resistant, rigid
creation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items
attached to the creation container prior to creation. In he 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 be
removed prior to creation and placed in a combustible creation containeL I/We further authorize he 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
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. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT = CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which he Funeral Home is authorized to remove from he remains of the Deceased
prior tc remation,and dis of as indicated:po
, ,- P�C
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 he Funeral Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and
irreversibly destroyed by prolonged exposure to intense beat and direct fume. I/We authorize the Crematory to open the creation chamber
during the creation process and reposition the remains of the Deceased in order to facilitate a complete and thorough creation.
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/w(e hertebytoauh�o�S�tches,nails,jewelr to y and precious metalsarate and remove �aa t�cremation of suchater enll'als noncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone 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. 77 7 r 1 T 7 1
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