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Bullard, Austin rrn%X OF QUEEVBUNY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name 19115-rltAl 9da Case # � - Date of Cremation < .2- l 1 / Time Cremation Started /� Time Cremation Completed -3d )O(M � Type of ContainerL'.CU Remarks : A1,41 N ,l3lJ/r/y�JQ o.�! to n`� l9iYVI f I1 i1 //�l10 !/►�I � M i i TOWN OF OUECNSBURY 13INE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) Crematorium 745-447'7 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 : US !irk (Name) (Sex ) (Street ) - (City ) (State) ( Zip Code ) p.y who died on �f-02� / ! day of 19 at V�(L-S f (`�IOiJ[�!I - �(LA�1 f� ar 0-I 4 (Place) (Address ) a Na.me, and . address of nearest living relative or name of person authorizing cremation : (Name) (Address ) Re hat i`onship .to the deceased Narwe of Funeral Home 2t5(�AI✓ -f' LJ�r�I IMPORTANT: rep resent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One) I' certtffy` that I 'have the full power and -aut:horization to arrange "for;' th'e'' cremati'on 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 '`a" nd save harmless Pine View Crematorium from any and all claims and"d'emand's{f--'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', : false or fraudulent . (Witness ) (Address ) (Signature of Relative r Legal Rep. and Address) Signed 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 : 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, Ouaker Road, Town of Oueensbury. 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. j Caskets . and containers must be of combustible water }material' No styrafoam or plastic containers will be accepted. t rr.r 5: fi The `question relative to cardiac pacemakers must be answered on4` the'''auth'ori .. n to cremate form before the remains will be acc•e pa.e.d. .;, " 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 sz0, 00 charge-for• this service. Cremation, Administration Costs and Recording Fee : .Adult $ 105. 00 Chi,ldre.n,_,,.,�(rge._ 13 months to 12 years ) sil•0. 00 Infants (to 12 month's )t+ s�j0, 00 stillborn X AUTHORIZATION FOR CREMATION AND DISPOSITION CE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING ned, certify,warrant nd represent that I/we have the full legal right and authority to authorize the creation,processing and sposonoeremains of{ 411',- r. m „s 1-LQ k h (hereinafter referred to as the"Deceased"). Name o Deceas Date of Death Time of Death ❑Am. ❑P.M. I/We hereby request and authorize(;,AbJ_ek �,Yl1f}� (hereinafter referred to as the"Funeral Home")to Name of Funeral frome take possession of and make arrangements for the creation of the remains of the Deceased at / im;!"" V I/!': ol C,f;'451VIA (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we undersions of the Crematory ins of the are to the ere sssiothnat the and custodys and of the Fluneral Home. I/We hereby shall aauthor zee the Fun when eral Home cremated arrange for the dispositiondof the returned cremated P Y g remains of the Deceased as follows: Is special handling required? ❑Yes 51 No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No Deliver to 'Ivw, 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: ❑ 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. of eased d herein shall performed in The laws cremation, tEe rules,ng and re regulations andn of policies the CrematoryimyandcFuneral Home,and the following byte s and conditions: with all g g � P 1. 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 noncumbustible 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 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. I/WE 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 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 be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. 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,�e separated from the cremated remains of the Deceased and disposed of by the Crematory. 5 n limit bd ter ouhiorizenges,ltatclies,nails,jewelr to y and parate anel r s metalsnove ,and to diapoam the tion e of suchchamber at�ls 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 um or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the created remains of the Deceased in a container which is not designed for any type of shipment. R T„ Aa PIIPn+ Al „rn nr rnn+a;nPr ;a inan4ioiP.n+ +n acenmmndate all of the cremated remains of the Deceased. anv excess cremated . , 40 "Customer's Designation of Intentions" Name of Deceased.: ;`t 4 1 1,,1 Cremation: 9 - 7 i - ' 'I ► ~�` y (Scheduled Date) (Location) Manner of Disposition of Cremated.Remains: ® Burial at ems' ! 1 1`Z s' L7. 1 J t l` f...Y ❑ Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of this form. (Signature) (Printed Name) (Relationship to Deceased) (Address) (Telephone Number) "Cremated. Remains which shall not have been claimed. within 120 days from the date of cremation may be disposed of by this firm by placement in a columbarium." f f;�;�. J~� ��`�: 1=�l!~i! �_`li,J ��L�c. ( t , �,�-�/4{ 1 <�.,! ���Y1•T Printed Name of Funeral Director Signature of Funeral Director Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 WME:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96