Foss, Gladys TOWN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �— fi OI— DZEWIV
Name (�- /l 1�5 / SC✓ Case #i 0 1 /
Date of Cremat i cn
Time Cremation Started
1
Time Cremation Completed
Type of Container
y
I
Remarks :
Ai'91'N ao'?"V'aw o,! A6(y ''/9lM
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A f re, r
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
A
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:
GLADYS i=0- S j=L 1 I A.LL
(Name) (Sem)
r� �
1 ��I InJL So f Jf4 /�,1/L: J&661S 42� M
(Street ) (City) (State) (Zip Code)
who died on day of 51 19 9$
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
AL &-C, (?�.&X l�e'7f 3AC};Son! Vi"G
(Name) (Address)
Relationship to the deceased S >��
Name of Funeral Home 26aAd +
IMPORTANT:
sent that to the best of my knowledge, the deceased has or
has no acemaker 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
gro less, fal a or fraudulent.
Wi ne (Address)
(S gnature of Relative or Legal Rep. and. Address)
Signed on this date :_` 5�
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIO ,&CONCERNING CREMATION.
*M%ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CARh' LZ FIJY BEFORE SIGNING
I/We";the undersigned, cerh�y,warrant and represent that I/we have the�u�l legal right and autlwrity to authorize the cremation,processing and
disposition of the remains of (= y,f j 5 c/5 E- SS (hereinafter referred to as the"Deceased").
Name o D �
Date of Death �L� Tune of Death �� ❑A.M. K PM
I/We hereby request and authorize ` tiff h! �' [:�v� Y (hereinafter referred to as the"Funeral Home")to
Nameo Rineral ome
take possession of and make arrangements for the cremation of the remains of the Deceased at V I C:;V( ( '.•` l Ytt�=r"2.
(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
understand thatservices obligations
mees�be th when
ar remains
Deceased
ecre
the posses and custodY of the Funeal Hme. I/We he b aoorize the Funeral Home tto nge for the dispositionof thea ed
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: suitable
/for shipping: El Yes ❑No
Deliver to l D I N C V t LE w {, f`'7 —11=�f�}� ( L)(-�L;N 5 !2i t' !q,Y. Cemetery
N.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 Service.
Th cremation
rocessing and dispsition of the remains of the
eased
rein
hall
e performed in
governing laws,ode rules regulationand policies of the Crematory and cFuneral Home,ya dythe following bg terms and conditions:
with all
1. The remain of the Deceased will not be accepted for cremation unless received by the Crematory in a eomhustihle, 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 remain 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 remain of the Deceased to he
removed prior to cremation and placed in a combustible cremation'containet 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 0 DO NOT [K] 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
_. o{ImpantedTe- e ` 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 he placed in the cremation chamber and will be totally and
irreversibly destroyed by prolonged exposure to intense beat and direct flame. I/We authorize the Crematory to open the cremation chamber
during the cremation process and reposition the remain 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 remain of the Deceased and disposed of by the Crematory.
5. n�eot hmeted tby o,hinges,latches,nailsrize the ,je jew to elry and precious metalarate and remove s and to dispose of sm the cremation uch h ateriialsmber all noncombustible materials, including, hut
6. Following cremation, the cremated remains of the Deceased, con isting primarily of hone 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