Rushby, Ethel TOWN OF QUEEVBU-Ry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � x ?Z
Name ,/--, W-4 US Case # /
Dat e of Cremat i cn
i
Time Cremation Started Q Q y14 AM �
Time Cremation Completed 2rsS/91M
Type of Container 43Qn C/7S�i�' lS�c/��OF �Tf1�I�i9�
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Remarks ;
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TOWN OF ❑UEENSBURY
PINE ViEH CEMETERY e7��
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-447'7 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 �t h e remains o f : G
(Name ) - (Sex)
(Street ) q (City ) (State) ( Zip Code)
/ � _.
who died on day of JF 19 /ccyy
R
at
(Place) (Address)
Name. and , address of nearest living relative or name of person
author.i.z i ng cremation :
(Name) (Address )
Relationship to the deceased (so
_—.,.r
Nartae o`f Funeral Home /' G4-Al � OL-AfeU/ LWUfe0-L- u,f�ye
/, 1y6—C
IMPORTANT
sent' that to the best of my knowledge, the deceased has or
has no acemaker in his or her body. (Circle One)
i
I` cert'i"fy" that I have the full power and •aut:horization to arrange
"for- th'e'• cremati'on of the remains and to direct the disposition of
the' crem(atted 'remains that an personal
y p possessions have either
been removed or may be destroyed, and agree to protect, defend
and s'ave. h.armIess'` Pine View Crematorium from any and all claims
and' 'demand"s'{#`for' loss 'or damages which may be made against them by
reason` of. or connected with the cremat.ian of said remains as
directed, whether such claims or demands are or are not wholly
gro ndl'es-s' .`'f s' r 'fraudulent .
(Witness ) (Address ) / (
(Signature of R tivge� or LegalRep. an Address)
Signed on this date : ! /6
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
I . ' 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
container. Caskets , and containers must be of combustible
�natrer'ital .' No styrafoam or plastic containers will be accepted.
5'. Thv `question relative to cardiac pacemakers must be answered
on' th.v ''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 s20. 00
charge—for- this service.
Cremation, Administration Costs and Recording Fee : -Adult t185. 00
age._ 13 months to 12 years ) il ],0. 00 Infants ( stillborn
to 12= month's )t.;'.s�'0. 00
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, ce ,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
' disposition of the remains of � t r (�. t 1 l._�;/ " (hereinafter referred to as the"Deceased").
Name ofDeceased /
Date of Death f �, /t; Tine of Death .J 9A M. ❑PM.
I/We hereby request and authorize -k L iI&j k"): AvJ AJ, (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
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
la services Home. shall he
cremated remains Deceased are crematedto
thepossessionand custody of the Funeral I/We herebyaauthoorrizllFuea Home to arrange the disposition of the
remains of the Deceased as follows:
Is special handling required? ❑Yes IN No Describe
Description of urn or container selected: :` :! LZ < '-�L ,it L Suitable for shipping: Yes ❑No
ER Deliver to , . ✓ ,t 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, 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 terms and conditions:
1. The remains of the Deceased will not he 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 im lanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
when placed in the cremation cha Ser. The Crematory will not cremate any human remains which contain any tyype of
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we herehy
authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased
prior to cremation, and disp_S�W of such items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT ] 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
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 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. Me 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. ' 7 J A� P 77 7
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•
REGAN&DENNY FUNTE RA L S Z.'.4
53 Quaker Rozd
Queendmy,Now Ybek 12E,t!4
(518)792-1114
"Customer's Designation of Intentions"
L Name of Deceased: L
Cremation:
(Schell.1 I ell Date) (Location)
Manner of Disposition of Cremated Remains:
D/Burial at L(W (-1M1 LC! F-1 Return to Family
El Entombment at 0 Other (specify):
i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
Oig)k-ture)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone N—ler)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Sid— re r tu of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: (Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (Manner of Disposition)
(Location)
(Date)
Name of Person Malting Disposition Signature Date
#9 WHnE:Funeral Home Copy YELLOW Family Copy PINK:Crematory COPY CUSINnN Rev.4/96