Armand, Henry ..Y.k:ia L_G ..... ...
7O q+N OF QUEEVBU- Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C1"'id/1 17 k-141l
Name Case #
Date of Cremation
Time Cremation St art edu T a- /71M
//
Time Cremation Completed `'elr o n W films '
Type of Container ��DB;:JA/t'D
Remarks :
TOWN OF OUEENSDUR
13INE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) 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
cremate the remains of :
1f�N2y Ft2(``A16 IVIA LL �..
(Name ) -' (Se►c)
,(Street ) (City ) (State) (Zip Code ) c
who died on a ij(_l� day o f C, 199 b/
at V' C,oltL-`WS!A l2L
(Place) (Address )
Name: and , ad' dress of nearest living relative or name of person
a.utho,ri.zing cremation :, .
(Name) (Address )
I
Relationship t'o ' the de ceased
'I:Narw',e orf.'FuneraI Home + .X)=/ a ---
r 'IMPORTANT:k
"I'rr- ' sent'"that ''to the best of my knowledge, the deceased has or
has no ,pacemaker in his or her body. (Circle One )
I'r cert�i'"fy'tthat I 'have the full power and •aut;horization to arrange
`for" the '.cremation of the remains and to direct the disposition of
theL cre �ar "`re-cremated mains that an personal
y p possessions have either
been r. emo,yed or may be destroyed,, , and , agree to protect, defend
and . s'ave,_..harmIess' Pine View Crematorium, from any and all claims
anWkV mands 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
groundl'es`s', .'false` or fraudulent .
I
(Witness) (Address )
(S ' nature of Re1a or Legal Rep. and Address)
Signed on this date : OCGL
� I
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, Gheck 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 ' Flo idays 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 -and authority 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 of
damages which may be made againstthem by reason of or connected
with the cremation of said remains and/or , disposition of said
remain:s' 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
cont'ai r.e n
i ,, ,, .1 ),• ,. Cask
ets and containers must be of cumbustible
rnat'er'ial .r' No st rafoam or
y plastic: containers will be accepted.
S: >a " The question , to card� ac pacemakers must be answered
on'4 �• ;thQ' auth'ori�zat i`on'
to cremate form before the remains wi l l be
p't eii.
• t v'. �yI1 , �'r.j'o:it :•7 . i .I 1
6:r' '� lJnles`s 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 t20, 1;►0
.---•char..ge:. fora th i s s ery r ce.
Cremation,' Administration Costs and Recording Fee : .Adult Ch,i-l.dr.e.n.,1. i105. a0
1(a9e•_. 13 months to 12 years ) tl ],0. 00 to 12r. monthts')t.4''j0. 00 Infants ( stillborn
ATTACH 4 AkrMORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE I 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, ce ,,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of �L;;/�fZ�l ��.Nt�it/`l (hereinafter referred to as the"Deceased").
K�a�+G�-,i Tune of Death/,,, A,,', ,►�'( AM. ❑P.M.
I/We hereby request and authorize Date of Death -4, (hereinafter referred to as the"Funeral Home")to
Name of one Home
take possession of and make arrangements for the cremation of the remains of the Deceased at /31n1 L• V!t v oZ
(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 custodv of the Funeral Home. I/we
understand are
to
c es and ugations of e.ee eheri the smains of the disposition d atthe p possession u�aY of the Funeral Home. I/We he bY aary uthooriz Funeral to arrange for the of the cned
remains of the Deceased as follows:
Is special handling required? ❑Yes IC No Describe ,SN 1--`f t-3/c:C I,l Z I
Description of urn or container selected: C tit-, {— Z suitable for shipping: k Yes ❑No
❑ Deliver to Cemetery
• Name and Address of Cemetery
Jl Release to family A l �l E./� lgL (d 6 1, 13 2.A i T-it
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
tion of the remains of
rein
hall
ed in
governing laws,/le rulesrocess, g and regulations and policies f the Crematory and°mod i ome,eand the following w bg terms and conditions:
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 noncombustible materials, I/we authorize the remains of the Deceased to he
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. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT ® CONTAIN ANY TYPE OR 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
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 here authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but
not limit to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
b. 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 I1to accommodate all of the cremated remains of the Deceased, any excess cremated