Bobbit, Louise TOWN OF QUEEVBU-1kY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , AA 1v `
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Name Act) , /�6 /7'8�=Case # /,g y
Date of Cremat i cn y
Time Cremation Started
Time Cremation Completed
Type of Container Dodo o2 /y.Dr C/7'5;�ej'E:/7"6—
Remarks :
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TOWN br WtEMSBlihv
pINE VIEW CEMETERY
CREMATUA I UM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetet^y 745-4476
AUtNUR I Zpt t UM TO COEMATE
The undersigned repd su
bject to its Rules and Regulation
authorizes
Pine View s to
in
accordance with an
cremate the remains of:
(Name) / ,� /
(City)
2 �Ivh6V� (State) (Zip Code)
idied
� day of 19
whonats
(Place) (Address)
Name and address of nearest living relative or nami of person
authorizing cremation:
�
�O b e '
/
(Name) (Address)
Relationship
to the deceased pro / � 7
Name of Funeral Nome �✓
IMPURTFINT: knowledge, the deceaised has or
I represent that to the best of my (Circle dne)
has no pacemaker in his or her body.
I certify that I have the full 'power and authoi^iiatibn to arrange
for the cremation of the remains and taldipossessions disposition
either
the cremated remains, that any personal
agree to protect, defend
been removed or may be destroyed, ms
and save harmless Pine View Crematorium from an
made againsty and lthemiby
and demands for loss or damages which may
be reason of or connsichdclaim5 or with e demands oare oorsaare not id awholly
direc d, whether
gro less, Is raudulent.
(Witness) (Addre s) f�^
(Signature of 11 1 e o ega and Address)
Signed on this date : GRC Q��G
DISPUSITIUN OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as olio s :
1 t Mai o
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, 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.
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 Hume handling the service. There will be a $20. 00
charge for this service.
Cremation, . Administration Costs and Recording Fees -Adult $185. 00
Children (age 13 months to 12 years) ill:0. 00 Infants ( stillborn
to 12 months) $'70. 00
i
AUTHORIZATION FOR CREMATION AND DISPOSITION
NOTICE THIJ jS A.UGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CO CIrR&ING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
undersigned, certify,warrant and represent that�ve ha a Ul l gal t and authority to authorize the cremation, processing and
pn of the remains o{{ ✓ F . C ��j (hereinafter referred to as the"Deceased").
Name of Deceased ` (�'
Datef of Death 0 I`ume of Death ,, ❑A M. XP.M.
I/We hereby request and authorize �� (3 GJ i t`�° a-• t�l, (hereinafter referred to as the"Funeral Ho a") to
Name o FuneralHome
take possession of and make arrangements for the cremation of the remains of the Deceased at M i r"v y1-13t•-Y !�'1``�
(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 custod of the Funeral Home. I/we
t the
he C
be
are
to
theunderstand
thaand custodys and of the Fuuneral Hogations me.e. I/We here b authorize the Funed hen the era Home toted arrangemains for the dispositiondof the crmt cremated
Y YP
remains of the Deceased as follows:
Is special handling required? ❑Yes ❑ Describe
Description of urn or container selected: suitable for shipping: ❑Yes ❑No
❑ Deliver to / Cemetery
/ � J
Release to fare" J7fja le e ✓,S/c^i" r A, q t�t t 7 /cr !/�f !`f j j�
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
* T,uneral 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, processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terns 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. UWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT = CONTAIN ANY TYPE OF IMPLANTED MECHANICAL,OR RADIOACTIVE DEVICE.
Please initial one.
Lasted 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 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 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 hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not limited to,hinges,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.
R T„ +l,a ---+ A. „r„ nr -+a;mar ;a ;na„MAP.n+ +n aaenmmn(Lte all of the cremated remains of the Deceased. anv excess cremated