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Keene, Bethenia TURN OF QUEEN B 21WY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name e—+h -CN i & - 1< e.leAle,- ase # ! IZ Date of Crematicn Time Cremation Started Time Cremation Completed 'a� L pe m , Type of Container Bno. [1rCAS m rw/ * G �^ Remarks : ,4141'N // 11 �J TUWW bi' bUttHSHUhY pINE VIEW CEMETEnY CREMRTUOIUM Quaker Road, queensbury, New York 12804 Phone (519) Crematorium 745-4477 or if no answer Cemetel-y 745-4476 Aut"URltat1UW TO thEMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains f: Cti�Ct �zq� T e-kn--4 lPa4 ( (Sex)` Name)) I e (Street ) City) istate) (Zip Code) who died on day of 19/ at l �✓6 �Y Gl' (Place) tAddress) . Name and address of nearest living relative or name of person authorizing cremaftion : {/S�L2 QG Address) (Name) Relationship to the deceased o' C� rVl� 11n Name of Funeral Home , IMPORTANT: + at to the Best of my knowledge,a the deceased has or I represent th has no pacemaker in his or her body. (Circle dne) I certify that I have the full 'power and alithoi^i iat ibn to arrange for the cremation of the remains erd to direct the possessionsshaveteither ion of the cremated remains, that an personal 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 or demands are or are not wholly dire ted, whether such claims gr ndless a r fraudulent. (Witness) (Address) (Signatu of Relative or Legal Rep. and Address) Signed on this date : d �� DISPUSItIUN 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, nULES AND nEGULATIONS 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, Uuaker Road, Town of Uueensbury. 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. S. 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 Fees •Adult $I85. 00 Children (age 13 months to 12 years ) f11,0. 00 Infants ( stillborn to 12 months) $'70. 00 f P ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE IC : 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,wa and p sent that I/we ha e full legal right and authority to authorize the cremation,processing and disposition of the remains o}{ i�t _ ( ^e !7 (hereinafter referred to as the"Deceased"). —� Name of Deceased / to of D th Time of Death ❑AM. ❑PM. I/We hereby request and authorize ( ( (hereina referred to as the "Funeral Home") to 9.e of hineral Home take possession of and make arrangements for the cremation of the remains of the Deceased at � t h e" (hereafter referred to as the"Crematory")• Name of Crematory I/We aixthorite 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 tie Deceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the dipposition 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 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. 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 Servic Tile disposition of remains of governing laws,,the rules, regulations ons and policies lof the Crematory and Funedral Home,authorized herein he follow he g terms performed nd conditions:rdance with all L. 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 noneumbustible materials, I/we authorize the remains of the Deceased to he removed prior to cremation and placed in a eomhustible 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 im lanted 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 FV1 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 r 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 place:"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. n�e�t hereby.authorize the latches,nails, jewelr to y and precarate aous meta remove ls, and to dispose of suchm the cremation materials. ll noncombustible materials, including, but 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.