Oakes, Grace r1 nWN OF QUEEVBU-'kY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 91 2 J=
Name (?WkF y/g/�,,�� Case #
Date of Cremation_1/ — /'
q /
Time Cremation Started //®Q
Time Cremation Completed
Type of Container
/ C
Remarks:
11 ll
i
i
TOWN OF QUEENSDURY
12INE VIEW CEMETERY
A
CREMA'rOR IUM
Quaker Road, Queensbury, New York 12804
Phone (516) Cr-einatorium 745-447.7 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CRE14ATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
(Name) _ (Sem)
(Street ) - • (City) (State) ( Zip Code ) r�
who died on 3 day o f /4,^,Vl/v1 19 f 3
at
/�'
J. ``\!�(�..•k futJP2-s Jr-4 G
(Place) (Address )
Ne:m,e: anA, address of nearest living relative or name of person
autho.r.i.z i ng cremation :
- �4M1� OefJ�(�S `� f�5 (Jt7.+(t1 tiV(:• SIJ (14 I`A)l•S
. •,�.;(Name) (Address)
Relationship to the deceased >C ��
Natwe "off:'Funeral Home ,D CAI r<_Y
'i
IMPORTANT '
If?represent"'that ''to the best of my knowledge, the deceased has or
has no .pacemaker in his or her body. (Circle One)
� 'I► cert`'i'fy-'that I have the full power and •aut:horization to arrange
`for- the ':cremation of the remains and to direct the disposition of
thel cre'mla'tV'd e`mai'ns, that any personal possessions have either
been r, eso..yed, or may be destroyed, . and agree to protect , defend
and :s*ave,._harmle.ss- Pine View Crematorium, from any and all claims
and.. 'd•errand"s','•)Ffor '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 o•r . are not wholly
groundfes's, .'��faI s'e or 'fraudul ent.
(Wi es ) (Address )
ignature of Rel ive or Legal Rep. and Address)
Signed on this date :
1
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, 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 Flo lidays 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 Oueensbury.
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 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
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
remains. , permit must accompany the
4• ., All , remains must be encased in a casl<et or suitable alternate
cont:afi n'er.
Cas,liets and , containers must be of combustible
mat�er'i)a1.r -No st rafoam or I Y plastic' containers will be accepted.
5•`�� The 'que,st i on relative at i ve to card: ac pacemakers must' onl" th'v`''autFi'oI,"; 1 on` to , cremat a form before the remains awi 1 1 answered
accepted.a.:_,rr,;. • ;
b: Lin Ie..s?s oth 1.er arrangements are made th.e cremated remains will
mailed -via Registered U. S.
to the f Mail within three days of cremation
to uneral home handling the service. There will be a s20, 00
•••char..ge:.•,for—th i s s ery i ce.
Cremation,'
Chi,l.dr...e. Administration Costs and Recording Fen.,,. „(age.,. 13 months to 12 years ) s11,0 e : -Adult s105. 00
. 00 Infants ( stillborn
to 12 mo'nthis')t''s j0, 00
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET 4"
HERE NOTIC&THI+S-TS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
e,the undersigned,cert. 1
warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains #' 1 , {' (hereinafter referred to as the"Deceased").
Name o Dec
Date of Death IiZg 'I nne of Death ;"C ❑A.M. ,O PM.
I/We hereby request and authorize J'ZE(�Ax,f '� {� : N 41y (hereinafter referred to as the"Funeral Home")to
Name of Funeral H me
take possession of and make arrangements for the cremation of the remains 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 custody of the Funeral Home. I/we
understand
services obligations f�e Cre es fulfilled
hHome cremated remains
are returned
to
the Po possession and custody of the Fneral Home. I/We he b authorizethe Funeral oaangor the disposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes iiO No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
iQ Deliver to { '{� Q C U (J:�141/,A� 1 J r v ' ` }` 011 V)[ S —Cemetery
Name and Address of Cemetery
❑ Release to family
Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
"K 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
rein
hall
ed in
dance
cremation,
laws/theorules,rre and
ulationss anddisposition
of the Crematory and Deceased
FuneralHome,authorized
aand the following w beto s and conditions:
with all
governing � g policies r1' g
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
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:
Deeaiptim of bVla.W Device Disposition
Description of Implanted Device Disposition
If no instruction for disposition is given, such items may he disposed of ae 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 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 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 to accommodate all of the cremated remains of the Deceased, any excess cremated
_-__-__'-__-`���__ __�___�•__ _ ______�______�l_.�_�_���_L_�_J 1_1L_�i..«,..._�L7_.._.. L..�.J.L....«_LL LL..«..:.Y_.�.....« ,........«L:«....