Harris, Floyd TowN OF QUEEN,,,5BuP.,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director R L � !'y ►`� �i(/ /�/ //, y
Name �40� 85 Case # / h
Date of Crematicn — � ?—
Time Cremation Started / ' / y
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Time Cremation Completed ' Q / m
Type of Container �V2
Remarks : L/'✓
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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
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Floyd K. Harris Male
(Name) (Sex)
2 Buena Vista Avenue Queensbury, NY 12804
(Street ) (City) (State) (Zip Code)
who died on 23rd day of Feb. 1998
at Glens Falls Hospital
(Place) (Address)
Nave and address of nearest living relative or name of person
authorizing cremation: j
Geraldine Harris - Same as above
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home
Regan and Denny Funeral Horpe, Queensbury
IP PORTANT
I represent that to the best of my knowledge, the deceased has or j
has no 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 j
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.
(Witness) (Address)
v Same as above
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Feb. 24, 1998
4-
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, 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
r 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 o-
the authorization to cremate form before the remains will
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 NOTICE THIS IS A LEGAL DOCUMENT. IT NTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ti•d CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned,c��{y,warrant and resent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of1Q d HaP�'i (hereinafter re{erred to are the"Deceased").
Name o D
Date of Death Feb_ ?'�_ QfI Tune of Death TT` ,� '�A-M. ❑P.M.
I/We hereby request and authorze Re an and Senn 6 ral Home (hereinafter referred to as the"Funeral Home")to
Nameo Fune Home
take possession of and make ements for the cremation of the remains of the Deceased at Pine View Cremate v
(hereinafter referred to as the Crematory"). Name o Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custodyof the Funeral Home. I/we
be
to
the understand sioonn and custodt the ys ai�d of fhe Funeral Home.ations e.eI/We hereby authorize tthheeFun when
eral Home to ar arrange for the dispposition Deceased
of the returned
r meted
P Y
remains of the Deceased as follows:
Is special handling requ"d? ❑Yes 2 No Describe
Description of urn or contained selected:l 9( 1&hZY OkWTOLD (. IA&-eZAd Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
i Release to family �. /j 01 iv 4a r'.�-
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 loss or damage of cremated remains shipped via Registered Mail with the United
States Postal Service.
The cremation, romssing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws, e rules, regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
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 noncombustible 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. 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. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT EA 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
i.
Des.-1 ho�aq(Jvv6tedDevice .. „`;=" - Disposition
If no instruction for disposition is given, such items may he disposed of ailhe 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 he 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,jewehy 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
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