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Flint, Lester CIO UN OF QUEEV B UJJ Y PINE VIEW CEMETERY AND AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director ,C_6� / 0t_ ,6:�z/,j Name /j / /l /c:7`41'4 / Case # Date of Cremationf f l �;._3 —T6 Time Cremation Started Time Cremation Completed L tFlr� Type of Container Remarks : 'yq 11 Il z' TOWN OF QUEENSBURY PINE VIEW CEMETERY 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: Lester W. Flint Male (Name) (Sex) _ Hallmark Nursing Centre Granville NY (Street ) (City) (State) (Zip Code) who died on 20 th day of Nov .mb r 19 _ at Glens Falls Hospital (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Lester Flint, 3 South Rd. , Gansevoort, NY 12831 (Name) (Address) Relationship to the deceased Son Name of Funeral Home Regan and Denny Funeral Service IMPORTANT: I represent that to the best of my knowledge, the deceased(has or has 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, whether such claims or demands are or are not wholly grou ess, fal a or fraudulent. Ls) (Address) M(1 1- (Signat a of Relative orLegal Rep. and Address) Signed on this date : l ' d. © 9 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 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 . Z A=ORIZATIO FOR CREMATION AND DISPOSITION CH THIS IS A LEGAL DOCUME . IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATION IS IRREVERSIBLE AND F AL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING gne 1,certify,warrant and represent t I/we have the full legal right and authority toauthorize the cremation,processing and spostionote rem is of (hereinafter referred to as the"Deceased"). Name of Deceased Date of Death Nov. 20, 1998'r a of Death 1:35 X1AM. ❑P.M. I/We hereby request and authorize (hereinafter referred to as the"Funeral Home")to N e Home o take possession of and make arrangements for the cre lion of the remains of the Deceased at Rine View (hereinafter referred to as the"Crematory"). Name o rema ory I/We authorize the Crematory to return the crematAd remains of the Deceased to the possession and custody of the Funeral Home. I/we ins of the to the possession understand and custodt the ys and obligations of of the Funeral Home.e.e Crematory I/ e hereby auutthbnze�eF heral Home en the to as arrremange for the dispositiond are of the cremated P Y Y $ P remains of the Deceased as follows: Is special handling required? ❑Yes E l No Describe Description of urn or container selected: UONZZ kAxJ C �/� Suitable for shipping: ❑Yes ❑No Ja Deliver to Pine Vi ew Cemetery Name and Address of Cemetery ❑ Release to family N me of Designated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral I lorrie's agent ❑ Ship via U.S. Registered Mail* To: Name: Address: ❑ Other * Funeral Home and Crematory are not responsible or any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation, roeessing and disposition of the mmains of the Deceased authorized herein shall be performed in accordance with all governing laws,le rules,regulations and policies of e Crematory and Funeral Home,and the following terms and conditions: 1. The remains of the Deceased will not be accepte r cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container- The Crematory is authorizad to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to crem,ition. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberg , or other noncombustible materials, I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a co le cremation container- I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible c many 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 cham er. T1.e 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 c ation, and dispose of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 7,71 DO NOT = CONTAIN ATS Y TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioa.tive 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_aq i> action for dive n is.given,,such may J-disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased wil( be placed in the cremation chamber and will be Totally anil`" 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 rej nains 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 i be Deceased and disposed of by the Crematory. 5. Me 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 a Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement. an urn or other container- 7. Unless an urn or container suitable for ship nt is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type o shipment. 8. In the event the urn or container is insufficiei t to accommodate all of the cremated remains of the Deceased, any excess cremated .111 1 1 . 1 1 1 .- ,1-- U- -----1 T-T---__ A-- AUTHORIZATION FOR PLACEMENT I/We,the undersigned, hereby request and authorize R$ganand Denny Funeral Service (Name of Funeral Home/Cemetery) (hereinafter-ftfetred to as the"Company")to take possession of, and make arrangements for, the disposition of the cremated remains of Pine Lester W. Flint (hereinafter referred to as the"Deceased") in (Name of Deceased) accordance with and subject to: (a) the terms and conditions set forth in this Authorization; (b) the Companj's Mules and Regulations; and(c)any applicable federal, state,provincial or local laws and regulations. I/We hereby, certify and represent that the cremated remains being delivered to the company for disposition are those of the deceased, and that I/we have the legal right and authority to authorize the disposition of the cremated remains of the deceased. I/We hereby authorize the Company to make disposition of the cremated remains of the Deceased as follows: I 1. Placement in Interment space: l� V"J�1'�,�,PA (Garden lAWSpace) Name of Owner of Interment space, if different than the undersigned: ❑ 2. Placement in Garden or Area: (Description) ❑ 3. Placement in a Common Receptacle: ❑ 4. Other: Special Instructions: Date and Time of Placement: ® Yes ❑ No Placement to be Witnessed by Family ❑ Yes ❑ No Placement to be Performed by Family If no specific instructions are provided herein, placement will be performed by the Company or its agents at the discretion and convenience of the Company. Placement consists of depositing the cremated remains in a receptacle or interment space within a dedicated cemetery. I/We acknowledge that when placement is to be performed in a common garden, area, or rece tacle, particles of cremated remains of the Deceased are commingled with particles of other cremated remains. I/We acknowledge tat once the cremated remains of the Deceased are placed,they are unrecoverable. Unless otherwise specifically provided for herein, once placement of the cremated remains of the Deceased has been performed, the. Company reserves the right, at its sole discretion,to dispose of the container which contained said cremated remains. The obligation of the Company shall be limited to the disposition of the cremated remains of the Deceased as directed herein. I/We agree to release and hold the Com�any, its affiliates and their,agensts, employees,ea of successors and assigns, connection harmless the disposition and d of loss, damages, liability or causes o action(inclu g attorneys ff expenses g ) the cre ted remains of the Deceased as authorizesierein or with respect to the identification of said cremated remains as being 0 of thePecsed. j, Lester Flint Son 3 South(smu. , Ga-nsevoort, NY, 12831 (Print Name) (xe1 _1 oDl eceaeed) (Address) (Tel.No.) (Signature) (Print Name) (Relationship to Deceased) (Address) (Tel.No.) (Signature Owner of Interment Space, (Print Name) (Relationslup to Deceased) If different than the Undersigned) (Address) (Tel.No.) For the Company: Regan &F,Qenn Funeral Service. (N use-nsu 12804 �y Signature: Date: f 19 !y (Authorized Representative) WHITE:Funeral H e Copy YELLOW:Family Copy PINK Cemetery/Crematory Copy PLACEMENTAUT Rev.4/6 #13