Lambert, Vyra �o WN OF QUEEM5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director r 4— Pi
Name Case # /
Date of Cremation ` m
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Time Cremation Started /d a. "M
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Time Cremation Completed/6 r3 oZ- l�JI !M �
Type of ContainerDx
Remarks :
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7-139 1�,,m
9 rs An
TOWN OF UUEEN48URY
PINE VIEW CEMETERY
A
CREMMUR I UM
Uuaker Roadi Uueensbury, New York 12904
Phone (518) Crematorium 745-4477 or IF no answer
Cemetery 745-4476
AUT14URIZATIUN TU CREMATE
The undersigned requests and authorize! Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains off
agile) (SeN)
(Streit ) (City) (C'tat e) ( Zip Code)
who died on
d a y of
at /3 S� vN •(Address)
(Place)
Name and address of nearest living relatiVt or "MOW of per!<o►i
authorizing cremation!
�m 13 S o v
(Name) (Addre s)
1
Relationship to the deceased
Name of Funeral Nome milli IQnI `Ih�N�`+l'Rn/ 7—of'f�
1 MPURTAN F s
I re resant that to the best of my knowledge, the deciee, ed has or
no ace�nake in his or her body. (Circle One)
I certify that I have the full power and irectrthe dispositionnOf
for the cremation of the),remanyspersonal to d possessions have . either
the cremated remailrs, ed and agree to prate ct, 'Gdefend
been removed or may be destroyed, 9 claim 13
and save harmless Pine View Crematorium fbemmade anainstlthen by
9
and demands for loss to damages the icremation of said remains as
reason of or connected with
s or demands are or are not wholly
directed, whether such claim
gro dlesso fal a or fraudulent.
• S zda�
Wit ess) ( ddress)
(Signature of Relative or Legal Rep. and Address)
Signed on this dates
� aOoa
s I
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to iL-P-ti�4-4�
Other arrangements - please specify:
If pulverization of cremate remains 1s requet sed, 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.
urdaecessarrearrangements by
telephone for acceptance of remains
2 . Pine View Crematorium
is ocate Town ofdueensbud on ry rounds of the Pine
View Cemetery, Quaker Roa ,
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
persona]. 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 fra
must nt. This authorization accompany the remains . in addition to
a regular burial perm
4 . All remains mast be encased in a casket or suitable alternate
container . Caskets and containers
must
wil be of be accepted.combustible material .
No styrafoam or plastic containers
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 . Mall within three days of cremation to
the funeral home -!candling 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 ac."t_;itional $50 . 00 .
Sullivan•Min& Poker
407 Bay Rd
Clue -I ,a ury NY 12804
"Customer's Designation of Intentions"
Name of Deceased.: Vy Y► b ff10 f
Cremation: 9 !%,,„s Va,e W � ' 'r»A to P i u
(Scheduled Date) (Location)
Manner of Disposition of Cre/mated. Remains:
LJ Burial at 1,rh% r'tt,, f„ "etr ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a Copy of
this form.
(.gijdature) a
(Printed Name) (Relationship to Deceased)
(Address)
}1 (Telephone Number)
r
' "Cremated. Remains which shall not have been claimed, within 120 days from,t k4 hate of
cremation may be disposed. of by this firm by placement in a columbarium.". �Is
Printed Name of Funeral Director Si tore o Funeral Director Date,;,F8 J
F` 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 Making Disposition Signature Date
#9 WHTI'E:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
ATTACH' AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NUTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNI GC REMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFOR*E SIGNING
I/We,the undersigned,C. warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of rsnp f (hereinafter referred to as the"Deceased'.
Name of Deceased /
Date of Death 1 !?G Tune of Death 41 &AM. ❑P.M.
I/We hereby request and authorize z.t (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
take possession of and mare arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory Name Name Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custins od of the Funeral Home. I/we
' understand that the services and e Funeral Hoons me.�e.e Crematory shall be I/We hereby authorize Fued neral Home toen the nne for the dispositionD �of the are�r��cremated
to
the possession and custody o g
remains of the Deceased as follows:
Is special handling required? ❑Yes R;No, Describe
F ;
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to L �.��.�_ a,,. / �. Cemetery
Name and Addre s of Cemetery
El 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.
g erring laws,, a rules,rregulati and �sand policiessition ofhof the Crematory the
and Funeral Home, d the following b terms and.conditions:
ed in accordance with all
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 contain); 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. I/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 .
- Desenption offniplanted Device Disposition —
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home.
r 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 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 hone fragments, will be mechanically pulverized to
an unidentifiahle 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
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