Crocker, Agnes TORN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director9EG19N d- Z��iY/Yy
Name //����J /[dC/� Case # / 1
Date of Crematicn
Time Cremation Started d 'I �'►' 1 `
Time Cremation Completed
Type of Container 4JQQj? GZ22► Er
Remarks:
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A TOWN OF QUEENSIIURY I
PINE VIEW CEMETERY � •
A
CREMATORIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Cr'ebat or i um 745-447'7 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 :
&,U S C1 GkL5./&
(Name) - (Sex )
(Street ) (City ) (State) ( Zip Code )
who died on o 0, day of AaO 19 ^
(Place) (Address)
Naim,e: and , address of nearest living relative or name of person
authorizing cremation :
8 Li Tom,('v /a 131 9 �e I Lf X
(Name) (Address )
�. Rel,ationship .to the deceased
Natwe 'otf Funeral Home �c =(` AAl
-IMPORTANT:'
represent `that ''to the best of my knowledge, the deceased has or
has no .pacemaker in his or her body. (Circle One)
c'ert'i°fy at ' I ' 'have the ful l power and •aut:horization to arrange
'f'or`the7':cremati'on of the remains and to direct the disposition of
theycre,matle�d "`remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and,: s'ave,. harmless" Pine View Crematorium. from any and all claims
and}'('demand"s`{`!for','loss' or damages' which may be made against them by
rea son I of. or connected with the cremat.-ian of said remains as
directed, whether such claims or demands are or . are not wholly
groundl'ests', ."fals'e` or fraudulent .
(Witness ) (Address )
:i
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 41,3o
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
I . ; 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 Vi'ew 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 o'f kin' or other authorized person stating that they do have
the power . =end 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 , add.ition to a regular burial , permit must
remains. accompany the
ti• , Al remains must be encased in a casket or suitable alternate
c,o n t'a i n'er:
Cas)iets , and , containers 'must be of cumbust : ble
+nat�er'ital'.r �•No styrafoam or 1
►:gar: �,�.t, t ,. ;.,,., , p astic, containers w111 be accepted.
5• ln The question
`'' . ,
, relative to card! ac pacemakers must be answered
anj` th'e' authori zat i on' to cremate form before the remains accepted. will l l be'' ,.,..;,
6•f' '� UnleSS other arrangements are made th.e cremated remains will
be mailed .via Registered U. S. Mall within three days of cremation
to t•he funeral home handling the service. There will be a t20. 0(D
char..ge:...for.- th i s service.
Cremation,' Administration Costs and Recording Fe
13 month e : -Adult s105. 00
s to 12 'years ) tl ]•0. 00 Infants ( stillborn
to 12= monthls')1'+`•t j0, 00 . .
'ATTA'CH AUTHORIZATION FOR CREMATION AND DISPOSITIQN _ ,
BOOKLET
HERE NOTICE, HITI'9'A—IrGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, eerli{v,warrant and represent that Uwe have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o}{ ;l t' 1 (hereinafter referred to as the"Deceased").
Name of Deceased
Date of Death Time of Death //i 00 NA.M. ❑PM.
I/We hereby request and authorize 2 L-,A'4 y' 1sS� ''vrr���— (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
take possession of and make arrangements for the cremation of the remains of the Deceased at i 'tlVC vl(.: K
(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
shall be
understand that the s des and f the Funeral Home. I/We hereions of the by authorize Fued neral Home ten the o as arrange for the dremains of isppositiond are of the returned
r meted
to
the possession and custody o
remains of the Deceased as follows:
Is special handling required? ❑Yes �S No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
Deliver to --^ S C L;i`''i-724 ' Cemetery
Name and AMress 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. 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 cremation
isposition of the remains of
d herein shall
rmed in
governing laws,'de: es n egulatig and dons and policies of the CrematoryeandcFunedral Home,ea d the followinhg terms and conditions:accordance with all
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory 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 noncumhustible materials, I/we authorize the remains of the Deceased to he
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 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
s1
Description of 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 he placed in the cremation chamber and will he 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 he 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,jewely 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 um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
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