Pattison, Rollin TOWN OF QUEEVBU-' �Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Si
• I d
Name 146L/14 /�� Case # �S
Date of Cremat i cn f) — / TO
Time Cremation Started f/i l �� r M I
Time Cremation Completed / I'JT P! M N
Type of Container On6a
Remarks :
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TOWN OF QUEENSBURY j
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
c emate the re ins of:
F
(Name) (Sex) /�
/ G
E/1S S l aC 0 U
(Street) /� (City) tStat ) (Zip Cod19
who died on >7l/ day o �
at � ARL�
(Place) (Address)
Name and address of nearest living relative or name of person
au horizing creT,4�rx6�
tion:
iyJm1h
t (Address)
(Name) A>
Relationship to the deceased
Name of Funeral Home 5
IMPORTANT:
I resent that to the best of my knowledge, the deceased has or
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
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
oundl s, als or fraudulent )�JJ }'/1' \
• / ,<l P D1AR 6�
C ♦ ��
(Witness) , (AdAress)
rA
(Sig at re of Relative or Legal Rep. and Address) 1
Signed on this date : Q�g
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�j _
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
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 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 .
X
AUTHORIZATION FOR CREMATION AND DISPOSITION
CE THIS I-S�i LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATIOceN IISS IRREVERSIBLE AND FINAL. READ HIS DOCUMENT CAREFULLY BEFORE SIGNING
I/W the remains of warrant aci eft tl�a# ha - /leand authority to auk therete there{e to as the D sing eceased"d
p !V ( )•
Name o Deceas
_.. p_ `^ j� A.M. ❑PM.
/ ate of Death/./� � Tnne of Dth�(1 ea
I/We hereby request and authorize a ) - � (hereina(ter referred to as the"Funeral Home")to
Nameo )
take possession of and make arrangements for the cremation of the remains of the Deceased at //l t- C 1 z— 1 -1 (-"1 ��i r�'
(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
are
to
theunderstandopossession
a the d custodys and of the Fluneral Homons of e.e. I/We hereb a�or z�leFunhen the eral Homeed mains for thet dispositiondof the returned
cremated
P YY
remains of the Deceased as follows:
Is special handling required? ❑Yes K No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
[I 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 Service.
The cremation, rocessing 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 noncumbueAle 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 0 DO NOT EX] 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
Desction o f Ilanted Device_.--- - - ------ - Disposition — --- -- --.
If no inatructi�ion 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
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.
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
Name of Cemeter�/Furftral Home/
RECEIPT OF CREMATED REMAINS AND RELEASE OF LIABILITY
The undersigned hereby certify that they have the legal right to take custody and maize disposition of the cremated remains of
the deceased, and hereby acknowledge receipt of the cremated remains of:
NAME OF DECEDENT:
The undersigned further assumes full responsibility for the lawful and proper disposition of said cremated remains.
The undersigned hereby agree to indemnify and hold harmless the above named cemetery/funeral home, its agents and
employees from any and all liability, including reasonable attorney fees, and against any loss it or any of them may sustain in
connection with the receipt of, shipment of, or disposition of said cremated remains.
Further, the above named cemetery/funeral home shall be held harmless from any defects or faults of any container not
supplied by the cemetery/funeral home.
Date this /!� day of ---�f2 t�1- , 19
Address (..C' ! ! G /1/
Street City State zip
Sign ture
Authq • ed Representative SSN # Photo ID Relationship to Deceased
Signature:
n Authorizedresentatii�e SSN Photo ID Relationship to Deceased
Witness:
Representative of Cemetery/Fun al t
e
WHITE: Funeral Home Copy YELLOW: Family Copy FORM C04 REV. 12/91
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