Morgan, Dorothy To,74N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -S/ YI t 0(' y ,
Name ,UY &1 d1 M0 —r x Case # __IrM
Date of Crematicn
Time Cremation Started .12 �Q 4ql
Time Cremation Completed /irk® P/ l�'� '
Type of Container kJ6o n c146f-k-T IN, G S� ifv�r
Remarks :
A1,41"N
/A %a a P/M
1/ lI�% Id J 2
LL
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12604
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:
c,�-2�In' �Y) a2--2 .
(Name) (Sex)
UZ
(Street ) (Cit ) ) (State) (Zip Code)
who died on ( day of 19
at 2"-"- -bbf<i/)I
(Place) (Ad ress)
Name and address of nearest living relative or name of person
authorizing cremation:
(Na e) (Address)
Relationship to the deceased
Name of Funeral Home N V
IMPORTANT:
�I--s �yresent that to the best of my knowledge, the deceased has or
? has n 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 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.
4L( ietnss) (Address)
( i nature of a ative or Legal Rep. and- Address)
Signed on th s a _����97
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 .
ATTACH AUTHORIZATION FOR CRC r
(LET CREMATION DISPOSITION
xERE [CREMATION
THISISA LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING I/We,the orders' red,certi{v,warrant and represent that I/we have the full legal right and authority to authorize the cremation,Process
disposition of the�remains o .� a
` y r (hereinafter referr�to as the"Deceased
N axne or Dec
Date of Death Time of Death ❑A.M. ❑px
I/We hereby request and authorize���'�UC.n f i
Name o eral Home - hereinafter referred to as the "Funeral Home')to
take possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the `/
"Crematory"). T�-,,�I{" p. i 1(' ff JNam _�—
ory
Me authorize the Crematory to return the cremated remains of the Deceased to the possession and custod ofethe Fu of neral
-_ /r
understand that the services and obligations of the Crematory shall be fulfilled when the '� Herire'
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home o arrange for the dispositiondof the are creat to
ed
remains of the Deceased as follows:
Is special handling required? ❑yes -VNo Describe
Description of urn or container selected: 'f
Deliver to Suitable for shipping: yes ❑No
Name and Address of Cemetery Cemetery
El Release to family
Name of esig
❑ Scattering at sea by Funeral Home or Funeral Home'snagent te Family Member to Receive Cremated Remains
❑ Ship via U.S. Re istered 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, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,Ie rules, regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
1. The remains of the Deceased will be accepted f unless received by the Crematory in a combustible, leak resistant, rigid
not acc or cremation
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.
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 tyype 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 di se of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implant"echamcal 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 oI Implanted Device Disposition
If no instruction for disposition is given, such items may he 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 fame. 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.
5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
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 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. 11 tt tt
R Tn +L a. + +ho — — n—+ainnr is ir�an+hniun� +n �nnnrr......hl .11 n,+41- ______J
ATTACH BOOKLET AUMORIZATION FOR CREMATION AND DISPOSITION
—NQ
HERE TI F: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
ZjV;W,,�th,1111r1gned, ,,r*
warrant and resent that I/we have the full le al ht and aut�ori to au orize the cremation rocesaisposition of the remains of D0z'c-="'Y Plorgjn g authority authorize
Processing and
Name ot Dec (hereinafter referred to as the"Deceased").
Date of Death 1 1/2 9/9 7 �-, `_
h by requ d authorize 'Irene of Death �-d�9�1�1. ❑P.M.
I/We ere estan au orize `'11 iv�a,Min3Fian &Dotted
_ (hereinafter referred to as the "Funeral Home")to
take possession of and make arrangements for the cremation of the remain,of the Deceased at Pi n i
(hereinafter referred to as the "Crematory"). �' '`�' Cr"-` >_`I
f6%..
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod ed remains ofethe Funeral Home. I/we
understand that the services and obligations of the Crematory Shall be fulfilled when the to
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Homeotarrange for the disposition dof the are crmmated
remains of the Deceased as follows:
IS special handling required? ❑Yee RkNo Describe
Description of urn or container s�"carjv
❑ Deliver to suitable for shipping: El-yes ❑No
❑ Release to family
Name and Address of Cemete Cemetery
�'
DesignsName of
❑ scattering at sea by Funeral Home or Funeral Home's agent
Family Member to Receive Cremated Remains
❑ Ship via U.S. Registered Mail*
To: Name: Address:
❑ Other
Funeral Home and Crematory are not responsible for any loan or damage of cremated resins Shipped via ��e United
states Postal service.
The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,Je rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
1. The remains of the Deceased will not he accepted for creation unless received by the Crematory in a combustible, leak resistant, rigid
creation 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, 1/we authorize the remains of the Deceased to be
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.
1 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 = 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
dt }!s +Dyed by Prolonged exposure to intense heat and direct flame. VW-authorize the Crematory to opera the cremation
uring 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 created remains of the Deceased and disposed of by the Crematory.
5 not limited to,hinges,e the latches nails, to separate and remove from the cremation chamber all noncombustible materials, including, but
1 ing , , ,jewelry and precious metals,and to dispose of such materials.
6. Following creation, the created 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 urn or container suitable for shipment is purchased, the Creatory 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 urn or container is insufficient to accommodate all of the created remains 4 th. n......i