Bennett, Lawrence rT-O WN OF QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
r Funeral Director f
Name j�AJgFC/q� ,L�01V g4-ZX Case # j-)
Date of Cremation + ► ?
Time Cremation Started IX, 30 P4 r ` f
Time Cremation Completed
Type of Container % D dffJW a12 /6 / t azg;Q �) B�
Remarks : G/► //`t/��D
J-K P,�, ,
TOWN OF WEEN4HURY
PINE VIEW CEMETERY
!4
CREM"M I UM
Quaker Roadt uueensbury, New York 12804
phone (518) Crematorium 745-4477 or IF no answer
Cemetery 745-4476
AUTHURIZATIUN TU CREMATE
The undersigned hraqudesgub�nedtau�ooitse,Ryles view
and Regulations' in
to
accordance with ,
cremate the remains oft
Ai:wOc
(Name)
(Street ) (City) (�ss �tate) ( Zip Code?
9
who died on day of
atZ o (Address)
(place)
Name and address of nearest liVing relative or name of ptri~ori
authorizing cremations
(Name) (Ad revs) ' \
Relationship to the deceased
ly 1 G -
r
Name of Funeral Nome
IMPURTANTs ►4nowled e, the dectesed has or
esent that to the best of my (Circle Une)
ha pacemaker in his or her body.
I certify that I have the full power and authorization to arrengt
for the cremation of the remains to dipossession% haverect the teith r
the cremated remains, that any personal rotect, defend
been removed or may be destroyed, and agree to p
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
in
reason of or conneuchdclaims or with e cremation o sa
demandsareorare "atawholly
directed, whether s
oundles false o f audulent. ) k /
(Witness) (Add es•s)
.
al Rep. and Address)
(Signature of Relative or Leg
Signed on this dates -R
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify: JK
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 cretgation 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 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 thre3 days of cremation to
the funeral home -handling the service. T!sere 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 .
s
w�
"Customer's Designation of Intentions"
Name of Deceased:
Ck�c9 .
Cremation: P 4r6k
(Scheduled Date) (Location) Jam' f
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.
(Sig tore(PyiR�AVA 14,
nted Na (Relationship to Deceased) -°c I 0
(�A1d ess) ^'
3
(Telephone Numher) ,
"Cremated, Remains which shall not have been claimed thin 120 days Iron,� ate of
c mation may be disposed of by thi firm by p ce n a lumbariu' " o�
Printed Name of Funeral Director Signature o eral Director Date z3 rl J
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED RtMAS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
BOTOKL T AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRR4VERSIBJ.E AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, ce ,Ivarrant re�pt I/ ev right and authority to authorize the cremation,processing and
disposition,of the remain.o b L..• (herein fter referred to as the"Deceased').
� Nameo D
Date of - '
Cj
" �`T`une Dea
I/We hereby request and authorize r �' � (herein r refe�d to as the"Pone❑Home")to
amPA
eo Fine Home _
take possession of and make arrangements for the cremation of the re 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 custod of the Funeral Home. I/we
understand that the services and obligations of the Crematory shall he 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 f No Describe
Description of um or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
of Cemetery
Release to family --�;- ate/
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 he 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 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
im lanted in or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
sot orize 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. LVE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT W CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all in lanted mechanical and.radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,an1dispose of as indicated:
Description of Implanted Device Disposition
Dei iption of Implanted Device -- -Disposition
If no instruction for disposition is given, such items maybe 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
4wmrsihly destroyed by prolonged exposure to intense heat and direct fume. 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
maybe separated from the cremated remains of the Deceased and disposed of by the Crematory.
6. I/Wereb7 authorize
the latches nails, a separate
�remove from the oue metals and o cremation chamber all noncombustible materials, including,but
limitednot g , ,j welq P , pose of such materials.
6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to
an unidentifiahle consistency prior to placement in an um or other container.
7. Unless an um 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 um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated