Robertson, John 70WN O,tr QUEEVBUgU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/ M 10c 1 1
Name rc/// r /tom ����Q/l�Case # _L
Date of Cremation 1 `�!
Time Cremation Started R/ M
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Time Cremation Completed �l 4-�r Ft m k
Type of Container Cam /1 U,60/0/1J0 /7` rC �� //
Remarks :
/ . M
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 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:
+sWN rrnCA�
(Name) (Sex)
(Street) (City) (Sta ) (Zip Code)
who died on day of ��� 1� 1 � 19
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation: of C I
(Name) (Address)
Relationship to the deceased
Name of Funeral Home su1111/� 1Y1� G � -
IMPORTANT:
I represent that to the best of my knowledge, the dace ed has o
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization 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 or damages which may be made against thew 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.
(Witness) (Address)
(Signature of Relative
� orLegal 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, 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 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 $195 . 00
Children (age 13 months to 12 years ) $115 .00 Infants (stillborn to
12 months) $75 . 00
* Additional $50 . 00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .
oOKLE At"ORIZATION FOR CREMATION AND DISPOSITION
HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRRF,VERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o}{ _ (hereinafter referred to as the"Deceased").
-" Name o�Decease
i Date of Death Time of Death ❑AM. ❑P.M.
I/We hereby request and authorize / (hereinafter referred 1,i,{ r !�<�,, ;- '- • 1,'' ( ereina er re errs to as the"Funeral Home")to
Name o Funeral Home
take possession of and maize arrangements for the cremation of the remains of the Deceased at
(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 custod of the Funeral Home. I/we
t the
s and
he
shall be
Deceased are
to
understand
possession and custody of the obligations
Hofmtee. I/We hereby authorizeen the cre Home totarrange for theed re mains ot disposition of theecr mt cremated
remains of the Deceased a follows: y
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
'Release to family '1'r i i J r e , / .
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
rocess
isposition of the remains of
shall
performed in
governing laws,/de rules,regulations ens and policies of the CrematoryyandeFunedral Home,yanherein
he follow g terms nd conditions:accordance with all
1. The remains of the Deceased will not he accepted for creation unless received by.+the_Creatory 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 he
removed prior to creation and placed in a combustible creation 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
I
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 '.DO NOT 0 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
- P ease 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
---- - — - e - - 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. Me 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 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.
hereh
horize
5 n�ylunit d touthinges,l tches,Crematory
jewelr to y and precarate ious me",a remove nd o m the cdispoetion e of such chamber at�]s,noncombustible materials, including, but
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 um 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.
8. In the--event the um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess created
r Singleton HealyFuneralHo-e,Inc.
407 Bay Road
Queensbury,New York 12804
"Customer's Designation of Intentions"
Name of Deceased.: -i7- f
Cremation: „T %
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at 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)
(Prim d Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"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 1yame of Funeral Director Sigtture 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
I