Rosati, Joseph Sr. 4
TORN OF QUEEMB U�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / ,�6:Aq G
Name � / l7 �dJ� 6 !' S/i / Case # 13
Date of Cremation �oZ-� ' Q
Time Cremation Started -mol" r(�
Time Cremation Completed r9/ry,
Type of Container D / CC�, - CE 7—A ..,
IX
Remarks :
l
-'33 h t m i
ti
TOWN OF UUEENS13UFIY
PINE VIEW CEMETERY
CREhtf1TOR I UM
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
crematt�e� the lremains of :
(Name) (Ser<)
h;�obrsc�rw; l} nr� • Cur�_✓zs Irv: )z�L1__
(Street ) (City) (State) ( Zip Code)
who died on I y day of S-rloi 2000
at
(Place) (Address)
Name and address of nearest living relative person
authorizing cremation : �: yu
C'Y C rj4
( am ) (Address) ;::
Relationship to the deceased
Name of Funeral Home
J
IMPORTANT:
I represent that to the best of my knowledge, the'"clad° a'3ed~ has or
has no pacemaker in his or her body. (C.ircIe
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to direct. theion of
the cremated remains, that any personal possessions haVireither
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 cremat:•io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, fa a or fraudulent .
(Wit ess ) ( ddress)
ig ture of Relative or Legal Rep. and Address)
Signed on this date :
TOWN OF ❑UEENSUUI(Y
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Uueensbury, New York 12aO4
Phone (518) Crematorium 745-447'7 or if no answer
Cemetery 745-4476
AU'rvioR 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 uf :
5 D' 12 •'
(Name (S"m
(Street ) (City) (Scat (Zip Code)
who died on 7 day of _ Scle 1� 2000
a t 1 c✓ts ��)is ,�-,�r� G 1 c �F411. '�
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
OF
(Name (Address) Qv«„s ):'L
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has (no acemaker in his or her body. (C.ircle One)
I certify that I have the full power and •aut.horization 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 cremat:•io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false r fraudulent.
(Witness ) (Address )
�" I a LL
(Signature of Relative or Legal Rep. and Addr )
Signed on this date : 22/,5J0Q
• REGAN & DENNY FUNERAL SERVICE
53 Quaker Road
Queensh",New York 12804
(518)792-1114
"Customer's Designation of Intentions"
Name of Deceased,: ) n� Xo'11 P I?o J a -,
Cremation: cT l 19 LJ20D
T (Scheduled T—
Date) (Location)
Manner of Disposition of Cremated. Remains:
❑, Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
( Ana
(Printed Name) (Relationship to Deceased)
9 wk;.��onv
(Address)
ru
Slur- '7 2X-�s-Y iz.
(Telephone Number)
"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."
)L�mI.;,I J --T� 7... gJ/; /,/v0
Printed Name of Funeral Director Sijnature o eral 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)
Date
f Person Making Disposition Signature
Name o � poj
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
l�' 031Rev.4/98
P�P�v AUTHORIZATION FOR CREMATION AND DISPOSITION
THISS 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,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living peFsoil who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of �l ic�o , Iq- (� a
(hereinafter referred to as the"Deceased"). �m
Date of Death 9/)y ) n p Time of Death .' ❑. A.M. AP.M.
I/We hereby request and authorize 1 0 (hereinafter referred to as the "Funeral Home")to take
ameo une me o
possession of and make arrangements for the cremation of the re aims of the Deceased at ,�, C
(hereinafter referred to as the"Crematory"). ame o rematory
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody 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�10 Describe
Description of urn or container selected: Suitable for shipping: ❑ • _ _:No-
❑ Deliver to
ame and MOMS 01 L.Meterye
❑ Release to family
Name of amMember 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 an rematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with t tes
Postal Service.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be perform ce with.
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the followin diti
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory e,
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,o hny-4-- -
noncombustible items attached to the cremation container prior to cremation. In the event the remmai eceased
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other no, Vie=
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combusti
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombu
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemaker$9,e.. ' ate a hazard`
when placed in the cremation chamber. The Crematory will not cremate any human remail;s?, :;any type of
implanted mechanical or radioactive device. In the event the remains of the Deceased contain` I/we hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices r the Deceased
prior to cremation, and dispose of uch items at its discretion. VWE HEREBY CERTIFY T INS OF THE
DECEASED DO 1-1DO NOONTAIN ANY TYPE OF IMPLANTED MECHANIC)1�h_ IVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is `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 be disposed of at the discretion of the�'uueit€al
3. The cremation container containing the remains of the Deceased will be placed in the crematioi be and"
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the tioa.
chamber during the cremation process and reposition the remains of the Deceased in order to facia at" ` uwt
,,.
cremation.
4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental:�ll other-personal
articles accompanying the remains of the beceased,may be destroyed during the cremation prod:. arise that if
any items,other than the cremated remains of the Deceased,are recovered from the cremation c ap 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 uding,
but not limited to,hinges,latches,nails,jewelry mW ,asid to dime of sw elk,
6. Following cremation,the cremated remains of the Deems*._ y�of bone fr, +- :�iiverized
to an unidentifiable consistency prior to ant in am or 4idi&comtaineit:
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cr W aced-in a
container which is not designated for any type of shipment, ;
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the> r 15
remains will be placed in a secondary container and returned to the Funeral Home,together with
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of thy}
tC �q`y AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98
N01d'Jr-Ti 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,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
amen
(hereinafter referred to as the"Deceased").
Date of Death �'f/y�/�ppp Time of Death S l$ ❑ A.M. *P.M.
I/We hereby request and authorize p r.n �► —D_ Fig _ 1�.. (hereinafter referred to as the "Funeral Home")to take
Q.o F ome
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). ame o reZ oratory
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody 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.ah
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains
Deceased as follows:
Is special handling required? ❑Yes �40 Describe
Description of urn or container selected: Suitable for shipping: ❑ = Yo R
❑ Deliver to
ame 21W AGUMSS at e ry _ -
❑ Release to family
Name of Designated FamilyMember to Receive Cremated Remains -
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via U.S.Registered Mail*
To:Name Address a
❑ Other 4'_`-
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail v fates
Postal Service.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be perform ' ance with:
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following- ditiee
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory iWo" � le,� .�`�
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,or it any o#it
noncombustible items attached to the cremation container prior to cremation. In the event the remain
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other nofl _
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in'a comb` on=eo
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombu
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemaker" ' Bate a hazard
when placed in the cremation chamber. The Crematory will not cremate any human remains y ain=any type of
implanted mechanical or radioactive device. In the event the remains of the Deceased contaiv-a el I/we hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices fro'_ .oft the Deceased
prior to cremation, and dispostsoff such items at its discretion. I/WE HEREBY CERTIFY T$ AINS OF THE
DECEASED DO ❑ DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL IVE DEVICE.
:.iese iniio e.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home i&a t ' o remove from the..
remains of the Deceased prior to cremation,and dispose of as indicated: '
Description of Implanted Device Disposition :-
pr
Description of Implanted Device Disposition -
If no instruction for disposition is given,such items may be disposed of at the discretion of the hµuner V 4
3. The cremation container containing the remains of the Deceased will be placed in the cremation hamper,and
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the` of
chamber during the cremation process and reposition the remains of the Deceased in order to f d
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental ~� hersersonal
articles accompanying the remains of the beceased,may be destroyed during the cremation pr : e that if
any items,other than the cremated remains of the Deceased,are recovered from the cremation`. Y ,be�sdparated
from the cremated remains of the Deceased and disposed of by the Crematory.
I _1-4 _
5. I/WelaEreb authorize the Crematory to separate.and remove from the cremation M_i' I ' �.,.
--o-- -MIiI ,tie c liii d remaws"o a mod, =
to im unjaentRiable conisistency prior to piacement in an am Awlodiei container. °`-
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the crenIW _ in a-
container which is not designated for any type of shipment. .
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of tlie' i d
remains will be placed in a secondary container and returned to the Funeral Home,together witltt
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the: