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Crosse, John TOWN OF OUEENSBURY PINE VIEW CEMETERY 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 I accordance with and subject to its Rules and Regulations to cremate the remains of: Je�^) t t) C�/�osSE S� 44 (Name) (Sex) / 7 /R 41 K Ov-1/N 1-?d �1/ /�80 4 (Street ) (City) (State) (Zip Code) who died on ,�5� day of 19 98 at /7 11,1,4i✓ !Fcl (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: tA aZ V.,V f?OSSE l i e-k dvEN R& EN5 h,�az 2 dr0 (Name) (Address) Relationship to the deceased � I j Name of Funeral Home Cu1(i✓�+ A-'A AAP*w M- 69720k j I IPORTANT: I represent that to . the best of my knowledge, the deceased has or > as 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. A Z ( i n ss) (Address Q ,c /c vim.✓ ?c' EEi✓sGu� (Signs ure of Relative or Legal Rep. and. Address) Signed on this date: II 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 herex 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 CREMATION AND DISPOSITION BOOKLET HERE THIS JS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMA ION. CREmAMWI ARREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY REPORE 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 GU L"' y S E (hereinafter referred to as the"Deceased'. Name Of Deceased / Date of Death `nne of Death ❑Alvt)�KPM. I/We hereby request and authorize S,ll iI gI• ("r (hereinafter referred to as the"Funeral Home")to Name o Funera Home take possession of and mare arrangements for the cremation of the remains of the Deceased at /' r` F Ll Name ot Crematory (hereinafter referred to as the"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 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? ❑Yeallo Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No A Deliver to ?;. l S mE?�-!� 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 Home's agent ❑ Ship via U.S.Re istered Mail* To: Name: Address ❑ Other Funeral Home and Crematory are not responsible for any lose or damage of cremated remains shipped via Registered Mail with the United States Postal Service. all The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed m accordance with governing laws, e rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: i 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, 1 resistant, rig, 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. We further authorize the Funeral Home or Crematory to an such noncombustible y manner it deems appropriate. make disposition of y mbustible casket in an lawful 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard e of when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any hereby implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, mechanical e p h 1 devices from the remains of the Decease authorize the Funeral Home, its agents and employees, to remove any such s at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DFCWE'D prior to cremation, and dispose of such item DO = DO NOT -CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one• I,sted below are all implanted mechanical&ad radioactive devices which the F u eral Home is authorized to remove from the remains of the Deceased prior to =,oration,and dispose of as indiaa - Description of Implanted Device Disposition t. 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 ds wt 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 hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not g 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. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated TOq+N OF QUEEVBUP.,Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director f�/ /Y` ( � f f Name /`I L Q5�E— Case # O� Date of Cremation —cz— l u r Time Cremation Started ESQ 4'm l Time Cremation Completed >iO� /I /'►� - Type of Container �J7x(�,/�TTI �J�/, /7J.�L� Remarks : r o2O /M l - 7, 144