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Daniel Hickey 707+N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name (GCE:v Case # Date of Crematicn Time Cremation Started ! z ! l© /J 1 r 1 Time Cremation Completed Type of Container T W+Po Remarks : 1� �� i 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: mak- (Name) (Sex) ID K ` rIkA Qrl�, 12ki3 (Str e ) (C )- (State) (Zip Code) who died on day of 'Ul 19 (Place) (Address) Name and address of nearest living relative or nano of person n authorizing cremation: (Name) (Address) Relationship to the deceased Name of Funeral Home IMPORTANT: t­rjWresont that to . he best of my knowledge, the deceased -Dr as Dnopacemaker in is 1w —hv-r 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 crenated 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 group -a' s, false or fraudulent. S (Witn4t&Jdyf' (Address) (SignRelative or Legal Rep. and. Address) Signed on this date : Ict 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 X.�_ 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 . , "Customer's Designation of Intentions" Name of Deceased,:" 1 Cremation• F t a - (Scheduled Date) (Location) J1 Manner of Disposition of Cremated. Remains: Burial at - ❑ Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Re�rnains and acknowledge receipt of a copy of this form. x rxy (Signs.) (Printed 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." Prints Name of Funeral Director Sigyature 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 ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE I;TOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULILY BEPORE SIGNING I/W�,the undersigned,certify,warrant and represent that I/wg have the full legal right and authority to authorize the cremation,processing and s - sition of the remains o t l... (hereinafter referred to as the"Deceased"). Date of Death { 1< Tnne of Death �� AM ❑P.M. I/We hereby request nd authorize {,: (hereinafter referred to as the"Funeral Home")to Name Dune H me take possession of and maize arrangements the creation of the mains of the Deceased at (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the created remains of the Deceased to the possession and custod of the Funeral Ho�. I/we understand that the services and obligations of the Crematory shall he 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 No Describe Description of urn or container selected: . Suitable for shipping: ❑Yes ❑No ❑ Deliver to �a # f i't + ) Cemetery j e and Address of C41netery ❑ Release to family 1•� 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 of eased authorized shall rmed in governing laws,, e rules, g and regulations and policiesosition of of the Clre atoryeandcFuneral Home,,and the followinbg terms and conditions:accordance with all 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 creation container prior to creation. 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 noncumbusbble materials, I/we authorize the remains of the Deceased to be removed prior to cremation 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 tyype of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we herehy 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. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT M7] 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 he placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flarne. 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 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 creation, 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. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated —L..r..l L—LL,-V........A T-T—..... 4,..-41—...:4.7 4-7 --.4...en--., --4..;—