Winchell, Robert �D OFQUEENSBUf�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director9,6, EA/V t/' a�rwN�
N am e 1/4C/E//j6�zk Case #
Date of Cremation 9" - C;d6�
Time Cremation Started :� /f Q
Time Cremation Completed
Type of ContainerC1ftffb'MfP
Remarks :
it � / / W71
1'O6JIV Ul= UUEENSUUI(Y
13INE VIEW CEMETERY
CREM Y1,O11lUhl
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-447.7 or it-- no answer
Cemetery 745-4476
AU'fl•IOR I Z11T 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 or :
(Name) (Seri)
(Street ) (City) ( tate) (Zi"p Code)
who died on �1 day of SCP = /I& 2000
(Place) (Address ) v "
Name and address of nearest living relative or am,�;yjof persun
authorizing cremation :
2oCQ1 tf 1cfJNcfEE,U, a�ttl/ y£ li hlo2�t�-
(Name) (Address)
Relationship to the deceased sat\
77,
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i.'
Name of Funeral Home �JGA14 -� hL--A(nl� ,
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C.irc1e 'on e)'
I certify that I have the full power and •aut;hori zat i ud`t o arrange
for the crvmati'on of the remains and to direct. the disposition of
the cremated rremains, 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 or fraudulent .
y4avv ��� rt �
n ss ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date :
Rit.,AN & DENNY FL)MRAI, SV4,!VWF
,13 Quakvt Read
Qut--rip,bury, Nviv York 12NW
"Customer's Designation of Intentions"
Name of Deceased: 12o o c,)z,-i-- A iaiAte,1161,L
Cremation: 10,(I�(6=Vt e V\I
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
0 Burial at Z Return to Family
11 Entombment at 0 Other (spec*):
Hereby designate the Di remated Remains and ac6owled&receipt of a copy of
t'
�- ;g"'spo
this form.
7-
Tsighat—)
(Printed Name) (Relationship to Deceased)
ailq/ L),s I melIq
_j
(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-77
IyAk-164b Me lviam��
Printed Name of Funeral Director Signature of Funeral 96,06 Date
or undertaker or Un&vtakd -
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 F6nn making Disposition Signature Date
#9 WHITE:Feral Home cow YELLOW Family Cc" PINK:Crematory C-ff CUSINTEN Rgv.4/96
G'$'`C
ww AUTHORIZATION FOR CREMATION ANI) DISPOSITION 031 Rev.4/98
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,certify,warrant and represent that Uwe have the full legal right and authority,and knJooww of no living erson who has a superior
A, W6LL
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name n - L�, r�G�
(hereinafter referred to as the"Deceased"). Date of Death f
Time of Death A.M. ❑ P.M.
I lama—
I/We hereby request and authorize 6h/n� N '�' 1�L"���;� (hereinafter referred to as the "Funeral Home")to take
ame ofluneral Home r
possession of and make arrangements for the cremation of the remains of the Deceased at
ame of urematory
(hereinafter referred to as the"Crematory").
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 [?�No Describe
Description of urn or container selected: Suitable for shipping: Yes ❑No
Cemetery
❑ Deliver to
,/� y� _ ,h/ ame an rasa o ame ery
* Release to family 1 rid 1�U Y f C� g-- 8m�y em r to ecerve rema amain
❑ 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 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 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 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 ❑ DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
J
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 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-aiid will be totally and
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize tliii Crematory too en the cremation
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate'-a.com and thorough)
cremation. � . . •. _ r.-':i+�:.`a ���
4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings and other person il
a
articles accompanying the remains of the beceased,may be destroyed during the cremation process. a further authorize that
any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they. may be separate
from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We hereb 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 pulverizer
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
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 Deceased,any excess cremate'
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary ui it or container.
.. ., ___ ,... ..,1 ,l,.0 4ho4--n with the PYPrPiRe of reasonable care and the use of the Crematory's best efforts,it