Stevenson, Grace rIOq+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name lr�//C. J / !/ �JQ/`{ Case It
Date of Cremation J
Time Cremation Started l"� rM
Time Cremation Completed /laA lofm1%
Type of Container ,C3��Tc'D a �, C//S,E-dam
Remarks :
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TOWN OF OUEENSDURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHOR I ZAT I ON 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 :
(Name) - (Sex)
t—,L14-5 rA(J2y
(Street ) - (City) (State) ( Zip code )
who died on ( day of C,c1,s 19
at LE11lS ej
(Place) (Address )
Na'
me: and , add ress of nearest living relative or name of person
autho,rizing cremation : ff
- R-CO rd)� PA�ft' Ui/fln 12,eo-/Z
,(Name) (Address)
Relationship .to the deceased 2���
Namef 'o;f Funeral Home Aei L bid V
IMPORTANT:
Irepresent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I' cerfify'"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' cr�ers'atred ` remains, that any personal possessions have either
been removed or may be , destroyed, and agree to protect, defend
.fir. j. f y�.,�. �..,.; ,�,
and save harmless * Pine View Crematorium from any and all claims
and' 'd'emand's'i-'for'•l'oss '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.
(Witnes (Address )
(Signature of Relative or 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_T
(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 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
mat�er'i�al ' No styrafoam or plastic, containers will be accepted.
5. 'n The `que•st i on re 1 at i ve t o card ac
on pacemakers must be answered
e" the"'auth'orization' to cremate form before the remains
acc-ep.t.ed. will be:f, .:-r
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 s20, 00
charge. for- th i s service,
Cremation, Administration Costs and Recording Fee : .Adult Ch_i.ldren,,_ (age,_ 13 months to 12 years ) t11 t1U5. a0
,0, 00 Infants ( stillborn
t 0 12,- monthls )',1.4s j0. 00
A TOT AUT
HORIZATION FOR CREMATION AND DISPOSITION-+
HERE NOTICE THIS IS.`A LEGA&DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
We,the undersigned, c�,warrant and nt that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of �ZA C,(' .5T- (hereinafter referred to as the"Deceased").
Name of Deceased
Date of Death .5 I l Time of Death QA.M. ❑PM.
I/We hereby request and authorize CZQ_ P►IJ ♦ (hereinafter referred to as the"Funeral Home")to
Name of Funeral ome
take possession of and matte arrangements for the cremation of the remains of the Deceased at V/c V+(
(hereinafter referred to as the "Crematory"). Name of Crematory
I/We authornd �i�ze the Crematory to return the cremated remains of the Deceased to the possession and custody of the FuneraleHome. I/we
ions
ned to
the posunderstsession and custodat the ys and of the Funeral Hofme.e.eI/W herey hall be hlleFuneralom o cremated
ar anremains
e for the disposition ofthe cremated
P Y Yg P
remains of the Deceased as follows:
Is special handling required? ❑Yes ® No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
® Deliver to 120 Cemetery
Name and Address of Cemetery
® Release to family 5 ( (E VrElyS c a
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.
The
isposition of
remains of
rein
hall
governing lalon,wsI Xe rules rocessinregulationsd and policies of the Crematoryyand Funedral Home,yandythe following w bg performed s d conditions:
accordance with all
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 noncomhustible materials, I/we authorize the remains of the Deceased to he
removed prior to cremation and placed in a combustible cremation containez 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
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
Y 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 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/Wyhlnut bdyto,uthorize the hinges,latches,nailer jewelr to y and precious marate and vetalsoand to dispose of aum the cremation �clniber matella noncombustible materials, including, but
not 6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will be mechanically pulverized to
an unidentifiahle 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. r
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