Ladabouch, Donna 7/n(WN of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 'cvkww Y
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Name 21VIVA Case #
Date of Crematicn �1�� / D
Time Cremation Started �i� / Im
Time Cremation Completed -
Type of Container QgS�,E"T
Remarks :
AlAiN ,(3lJl�iy�R o� ;�fftld ��M
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I _ TOWN OF GIUEENSBURY
'PINE VIEW CEMETERY /
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Cr-ematorium 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 the remJaiinJs- (of :
I�Ow/N A /`fit pDG/!r FE/Y)A Ae l..
(Name) '" (Sem)
(Street ) (City ) (State) ( Zip Code )
who died on /O day of ,/V 1918�
at //p Sn;1�4/ 1;-/Aws
(Place) (Address)
c
Naim'e: and , address of nearest living relative or name of person
a.utho.r.i.z i ng cremation :
_ �g/��1 �/�GI�DO NC�3��S h��soN S)'; .Sv G'�6NS �/-� �l� /✓V< /L�G3
(Name.) (Address )
Rel`at iI 1p to the deceased AuSbAr141
'Name "o{f�'Funeral HomeFGAN i, p�i✓tiI'
-.I MP'ORTANT
Itrrepresent, that ''to the best of my knowledge, the deceased has or
h�snpacemaker in his or her body. (Circle One )
cert'' have the ful 1 Y•i`f ''that ' I `
. . •y power and •aut:hori zat i on to arrange
`f' eor" th cremation of the remains and to direct the disposition of
thet crem�at)ed —remains, that any personal possessions have either
been r. emo,.ved or may be destroyed,, . and . agree to protect, defend
' ;a ,,S*aye:'harm Ie.ss'' Pine View Crematorium from any and all claims
� ' and{rdemandsi;•'for' '1`oss' '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
' groundVes's;""f 1 s'e` or 'f'raudu 1 ent.
(Wi ness ) (Address )
(Signature of Relatiy�Legal Rep. and Address)
Signed on this date : _��i�9 �
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 o'f 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 crenated 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
e mains.., a ' on to a regular burial , permit must accompany the
re .
ti• , A11 , remains must be encased in , a casket or suitable alternate
container. Cas.1iets and , containers must be of combustible
wa�t�er'ial . No styrafoam or plastic: containers will be accepted.
5: �� The question . relative to card4ac pacemakers must be answered
on.-1hv'au .;I '.. zati'on' to cremate�cc form before the remains will be
• IT, ram _ 1Cri'K:r r.
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, 0(D
• •-•char..ge:...for'-.this service,
Cremation,' Administration Costs and Recording Fee' : -Ad t105. 00
Ch_i.l,d.r...e.n,,.,jage... 13 months to 12 years )t monthis') sl ]•0, 00 Infants ( stillborn
o 12r. l+'s`j0. 00
nr�KLE AUTHORIZATION FOR CREMATION AND DISPOSITION
.�f50KLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING @*EMAiON.
1CREbM77TONTs IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING r
�e disposition
certify,warn t and represent that 11w e have the full legal right and authority to authorize the cremation,processing and
ition of the remains o} d.�t? ..7GG(we-A (hereinafter referred to as the"Deceased").
Name o Dec ,c,
Date of Death �/f 10 �r F� Time of Death /, ,L A,M. ❑Pm.
I/We herebyrequest and authorize G fin; `t (�Er'�''
(hereinafter referred to as the"Funeral Home")to
Name of Fun;ral Home �y��
take possession of and make arrangements for the cremation of the remains of the Deceased aft 'NF
(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
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
l Release to family PA/ph 1 v C1W 4v e`j Je.
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, recessing 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 noncumbustible 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.
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 x, y
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
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,jewehy 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