Schreiber, Fred rIn%N OF QUEEVBUS,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name #
Date of Cremation —;---- `7
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Time Cremation Completed f ��� �t �A i
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (516) Crematorium 745-447'7 or if no answer
Cemetery 745-4476
AUTI•(OR I ZAT I ON 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 :
(Name) "' (Sex)
• �G`7 b...nl�.��.r riL�� �4c21�.s . i a�Li L�s�c��,,� t1l.y eaF�.�
(Street ) (City ) (State) ( Zip Code )
who died on �! !� day of
(Place) (Address )
Neim,e: and•, address of nearest living relative or name of per-sort
r
a.uth, ,r.1,z i ng ,cremation :
a t •
,,'� ,. r, (Name) (Address )
�':{.
lr 1.
t; Rel`ationsliip to the deceased
NanrQ 'o'f 'Funeral Home_ Q,L(.,An( DIEWAN
IMPORTANT:
Irrr'epresent' tthat '•to the best of my knowledge, the deceased has or
has no pacemaker in 11is or her- body. (Circle One)
certri"fy'`Tthat Ihave the full power and •aut:horization to arrange
or"'they' cr�ematilon of the remains and to direct the disposition of
1 i r,; :>r
the cremated `remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect , defend
and). e l., p, , ,,•.,. . ,
:s'ave.. harmle.ss" Pine View Crematorium from any and all claims
and !�demand•s.. or Aoss' 'or damages' which may be made against them by
reason` " of. or connected with the cremat.io.n of said remains as j
directed, whether such claims or demands are or . are not wholly
groundVes's',' 'fals'e` or fraudulent .
t r7 - �ll/ �/S �CI6P,b' l►l.
(Witness (Address )
r(Si grPature of' Rela1tive or Legal Rep. and Address)
Signed on this date :
i
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, -xnd 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.
ti• , All remains must be encased in , a casket or suitable alternate
' conta+iner.
Cas,{yet s and containers 'must be of combust i bl e
mater'ilal'.`' •No st rafoam or plastic, containers will be accepted.
r ` 9:"xn � Thv `question , relative
on° th to card? ac pacemakers must be answered
z 'Q`'i°a utti'orizationi to to
form before the remains will be
` accept'ed.
OnIe"s's other arrangements are made the cremated remains will
be mailed -via Registered U. S. Mall within three days of
to t'he funeral home handling the service. There cremation
._char..ge� ,for—th i s • s ery ice. will be a sao, 00
Cremation,' Administration Costs and Recording Fee : -Adult 41p5. 00
Ch,i-1,d.r...e.n•,_,._„(age,. 13 months to 12 years ) tl ],0. 00 Infants ( sil
to 12r monthis•>1+'t70, 00 t 1born
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
H>bx>; NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTAN PROVISIONS CONCF,RIVIN�Gs,GREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned,dle�'fy,warrant and represent that I/we have the full legal ht and authority to authorize the cremation, processing and
disposition of the remains of t=�c'-�-t� G. SG 3�t2(�1 i�i (hereinafter referred to as the"Deceased").
Name o Deceae
Date of Death /I/M Time of Death /(i l�� ❑A.M.1c PM.
I/We herby request and authorize !'�,C�A rj + -0L (hereinafter referred to as the"Funeral Home")to
Name of Funeral Holne
take possession of and make arrangements for the cremation of the remains of the Deceased at
(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
t the
he Crematory
hall he
remains of
Deceased are
the posunderstand
ssio�naand custodys and of the obligations
H{e. I/We herebysauthorize�Funeral Home ed when the as are for the disposition t onn of theecr ma d
P Y g P
remains of the Deceased as follows:
Is special handling required? ❑Yes tail No Describe
Description of urn or container selected: Suitable for shipping: , .Yes ❑No
❑ Deliver to Cemetery, Name and Address of Cemetery
W Release to family -., S E f 314 IN Cy SC.K t2 C=_1 I I L
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
* Funeal 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
ed in
governing laws,/le rules rocessing and regulatians and policies of the Crematory the
and FuneDeceased
ral Home,authorized
a herein the following b terms and condition accordance with all
i. 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 noncurnbustible 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 impranted 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 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
D w ipH n of Irriplanted 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 placed in the cremation chamber and will be totally and j
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 j
may he separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We hereh 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 he 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
i
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