Holmes, David rroWN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � OL
Name P& /t,C/ Case # U l
Date of Cremation
Time Cremation Started
Time Cremation Completed Il,
Type of Container 00(0-D cf FTI
Remarks:
Ada b�67-0
t
T ACH - .zALUUORIZATION FOR CREMATION AND DISPOSITION
HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE 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 ( ! /l 4 �! '; (hereinafter referred to as the"Deceased').
Name of geceased
Date of Death i_ r 4, } Time of Death ❑A.M. ❑P.M.
I/We hereby request and authorize ' (hereinafter referred to as the"Funeral Home")to
Name Fune Home
take possession of and make 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 custody of the Funeral Home. I/we
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 [A No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
W Release to family
W 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
rein
e performed in
governing laws,/de rules, g and disposition of the regulations and policies of the Crrem Crematory the
FuneDeceased
ral ome,authorized
aand the following b terms and conditions:
accordance with all
I. 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 noncumbustible 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.-*h Mechanical&In the-cremation cham lan'ed in the The Cre�atoakwill- not cs of the remateda(suhumach as naremainsswhich contain an c.) may create a hy tazard
implaeri nted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/e 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. IM HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT E)E CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one. �T``�-
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
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 be separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We hereh authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not lun. to,binges,latches,nails,jewelry and precious metals,and to dispose of such materials.
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.
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` TOWN OF OUEENSUURY 6
PINE VIEW CENETERY
i.
CREMATORIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crlematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CRE14ATE
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 )
Uy 11c"122� Svv K �L&VS /�A1..Z nl.�. /��S 03
(Street ) - (City ) (`State) (Zip Code )
who died an al,� day of g
at G L ) S 17-A1,LS )4csy
(Place) (Address )
Nam,e: and,, address of nearest living relative or name of person
a,utho.ri.z i ng cremation :
NAiJOL'J P.01-1`'(LS q ' I c W4� sae. Soo�K GLE-95 P=AJ Ls
(Name) (Address )
Relationship to the deceased
---
Nar`e "oF uneral Home 2i5('Ah� 1 1��lrly'
r 'IMPORTANT:'
`rrepresent'''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 fu 1 1 power and -authorization to arrange
"f•or" the '.cremation of the remains and to direct the disposition of
thel,crematred `1`remai'ns, that any personal possessions have either
bee.n r. emo..ved or may be , destroyed,, , and . agree to protect , defend
and'1 '� b 1,�.p.. 1t.ys'.a O. .
and.. s'ave,.._har;,mless` Pine View Crematorium. from any and all claims
and..demand"s1�`jfo'r,,�'loss' 'or damages which may be made against them by
reason' ' of. or connected with the cremat.•ian of said remains as
directed, whether such claims or demands are or are not wholly
groundles`s, -'fals*e` or' 'f'raudulent . `
(Witness ) (Address )
(S ' gnatu of Relative or Legal Rep. and Address)
Signed on this date : _f/ ,,��Y _
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, Ouaker 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 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 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.
All I .remains must be encased
con tsai in , a casket or suitable alternate
n'er. + Cas,liet .s and , containers must be of combustible
+in a�tlerilal':`' •N o styrafoam or plastic, containers wi 11 be accepted.
E
She 'q.uestion. relative to cardiac pacemakers' must be answered
? on, the 'autFi}ori;zat i`on' to cremate form before the remains wi l l be
accepted.'
Unless other arrangements are made th.e cremated remains will
be mailed -via Registered to the funer U. S, Mall within three days •of cremation
al home handling the service. There will be a s20, 00
-- char..ge.:..for. th i s service.
Cremation,' Administration Costs and Recording Fee : -Adult $ lp5. a0
Chi_1_d.r..,e.n (age_. 13 months to 121 years ) % 11,0. 00 Infants ( st111 . 00
t 0 12 mo'nthls').th,'t.j0, 00