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McLaughlin, Janice Z O� Q21�� 5B UR y' PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director/�� Name // CG /I/C/� �C %/Y Case # 1 / Date of Cremation -ram 'I • Time Cremation Started ,?� Time Cremation Completed 11CC T Type of Container . Remarks : /j'I/4/ N ,�3lJ/�/�l�iP 4/Sr /i�l© /'�/l�►�l ' /M TOWN OF QUEENSBURY PINE VIEW CEMETERY a CREMATORIUM ' Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 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� 1\ (Nam ) (Sex) AA0 (Street ) (City) V( t—at-e�) (Zip Code) day of who died on y 19Z at (Place) (Address) Name and address of nearest living re�ativ o name of person authorizing c mation: sd �� ' (Name) (Address) T� Relationship to the deceased Name of Funeral Home IMPORTANT: I r esent that to the best of my knowledge, the deceased has or as no pacemaker in his or her body. (Circle One) I certify that I have the full power and authorization 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 cremation of said remains as directed, v1pether sucp claims or demands are or are not wholly gr undless, ris,eor ra dulent. 70 (Witness) (Address) &-Sa (Signature tf Relative or Legal Rep Address) Signed on this date: /� )6 , DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of th-e 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 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 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 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 three days of cremation to the funeral home handling the service. There 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 . ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE 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, t t I/we leg and utliority to authorize the cremation,processing and disposition of the remains of (hereinafter referred to as the"Deceased'. t.. - �' 1 Date of D th Tune of Death J M. ❑PM I/We hereby request and authorize :. s (hereina eferred to ae i'khe"Funeral Home")to Name-ofFune ome � � ` take possession of and make arrangements for the cremation of the remains of the Deceased at A•r (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 are understand that the services and lie Funeral Homions of�e.e C at I/We hereby ahuthbOrizfe t�heeFuwnhen the era Home to as ange for the dispremains of the Dositiondof the cremated to the possession and custody o remains of the Deceased as follows: Is special handling required? ❑Yes )l No Describe Description of urn or container selected: Suitable for shipping: Yes ❑No ❑ Deliver to Cemetery of ketery KRelease to family Name of Designated Farm y 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 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 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 im lanted 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 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 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: Description of Implanted Device Disposition Description of Implanted Device Disposition If no instruction for disposition is given,such items may he disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will he totally and ;reves 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. VW(e hereby authorize the latches,nailer j to ewelry and precious m remove from the cremation chamber all noncombustible materials, including, but metals,and to dispose of such materials. 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will he 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. E 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated - 111 1 1 . 1 -1 _—-----_J—LL_>~.._ _I I7--- + ae+l o..,.;+L A. nr rnntainPr- "Customer's Designation of Intentions" Name of Deceased* c,4— Cremation: (Schell ea Date) (Location) Manner of Disposition of Cremated Remains: 0 Burial at El Return to Family El Entombment at 0 Otherjspecify): I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of this form. (SignatVre) (Printed Name) t',x/ A (Relationaltip to Deceased) A) )i (Addyess) 5 (Telephone Numler) "Cremated Remains which shall not have been Claimed within 120 days from the date of cremation may be disposed of by this 4rm by p Cem nt in a c lumbarium.,, ,, ISZ- r J Printed Name of Funeral Dire;�'7-"^" .l l��. '� Signature of Funeral Director Date or Undertaker or Undertaker TO BE COMPLET�FOUDWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: Lp r r- (Actual Date) (Location of Crematory) Disposition of Cremated Remains: j(blrn�;Of a (Location) (Date) Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW.Family Copy PM:Crematory Copy CUSDTMN Rev.V96