Birnbaum, Sylvia TOWN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director F6:d lv' � N
Name �Y�!/ / �ft�lf��/� Case # JT 1
Date of Crematicn /j _ O y J
Time Cremation Started Z'r"//o
Time Cremation Completed D ' ze IgtM �
Type of Container
Remarks :
4-16 k2�0 71"w /9/M /
1 i iM I
TOWN OF ❑UEENSBURY /
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) CrIeinatorium 745-4477 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,:
(Name) (Sex)
(Str et ) —7 (City ) (State) ( Zip Code )
who died on L day of
at 11( Ycf
(PIa (Addres
Name; and . address of nearest living relative or name of person
autho.ri,zing cremation :
'(Name) (Address) }�
Re hat ion ship .to the deceased fQ� L�✓
�.... ,
Name 'of Funeral HomeYVA
' IMPORTANT
I`4rrepresent' that 'to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
'I' cert�i fy"that I have the ful l power and •aut:horization to arrange
for.' the' cr,emati'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
an
) ,..;,.. ,. .
d ' s'ave harmless Pine View Crematorium from any and all claims
and' 'd'emands�{�'jfor' foss 'or damages which may be made against them by
reason of or connected with the cremat.lo.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless'; .-'false' or fraudulent-4 .
fitness ) �dd�rs s )
0
j' (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 :
Mai l 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 weep
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
cont`ainer. , Cashets . and containers must be of cumbustible
mat�e'r'i�al.`' No styrafoam or plastic containers will be accepted.
S. '" The `qu.estion relative to card'. ac pacemakers must be answered
on the-auth'orization to cremate form before the remains will be
accep`ted. '':'
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
"char..ge.•.for. this service.
Cremation, Administration Costs and Recording Fe Ch,i e : .Adult s1p5. 00
,.ldr.en.;.;.,•, (age._ 13 months to 12 years ) s11,0. 00 Infants ( stillborn
to 12= month's ) +fs`j0. 00
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at El Other (specify :
I Hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
LI$`ignature)
(Printed Name) (Relationship to Deceased)
r r
(Address)
i
i
(Telephone Numher)
"Cremated, Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Sigrature 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 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
r �
tAUTHORIZATION FOR CREMATION AND DISPOSITION NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT'PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
ndersigned, certify,warrant andrepresent that I/wehave the full legal right andauthority to authorize the cremation,processing and
sposonof the remains off v f� _ k3 l r n i [ > t t n-, (hereinafter referred to as the"Deceased").
Name cMeceascJ
Date of Death l Tune of Death DAM. ❑PM
I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to
Name Home
i
take possession of and make arrangements for the cremation of the remains of the Deceased at 4 f c , 'V it, i
(hereinafter referred to as the"Crematory"). Nam�Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. Uwe
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes -k No 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
❑ scattering at sea by Funeral Home or Funeral Homes 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
isposition of the remains of
governing laws,/Xe rules,re regulations idons and policies of the Crematory eand Funedral Home, and ddethein foll all hg performed
conditions:
accordance with all
ro
1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leaf 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 noncombustible 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.
Mec
or
2 whenha laced in theactive cremati nces i chmbler.ted in The Crematory remainswill noht cremated y huma as naremainsswhich contain create
anaty hazard
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 die ose 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. k
Listed below are all implanted echanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the as
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 fume. 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 be separated from the cremated remains of the Deceased and disposed of by the Crematory.
6 n�ehmitedYtouhinges,thorize�ches,nails,Crematory
wlry to parate and precd remove frm the cremation�Ous metalsoand to dispose of u�c)�mat�)�,er all ncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will he 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. r 11 r 1 l
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