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Fourth, Rose TOWN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director &C 'G7 Name )��)e7 ��d1f / Case #, J Date of Cremat i cn /(�' — / — 9 V Time Cremation Started 5,� 341 r1 Time Cremation Completed �/ r1 Type of Container 96X 45 y/ Remarks: Am 1/4 r err/ /IV) 1 Il grr, TOWN OF OUEENSBURY 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: �2as �z'o L5hA1.12 (Name) (Sem) (Street ) ; (City) (State) ( ip Code) who died on - day of L�L(�, /f)/�L� 19 at /Z �- 1�iL)I J-L=2 12b (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: f'N?lGNHL-�� off% RGc�31C� 126 : (Name) (Address) Relationship to the deceased In Name of Funeral Home 4AI IMPORTANT: I represent that to . the best of my knowledge, the deceased has or a 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 damages7 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 gr ndless, false or fraudulent. (Witness) Sdress) (Signature of Rel t ' ve /or Legal Rep. and. Address) Signed on this date : %02/ -7 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. GAN & DENNY FUNERAI, SERVICE 53 Quaker Road Queewbury,New York 12804 (518)792.1114 "Customer's Designation of Intentions" Name of Deceased.: Cremation: 16>7 / t�l�-` Sl!G W Gzw-s a (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: ❑ Burial at 14 Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated Remains and aclznowledge receipt of a copy of this form. t. _ / z- Ile (signature) ' 1 )4 (Printed Name) (Relationship to Deceased) (Address) (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 plat ment in a columbarium." ZL�l P,6 L/�) /vi 6 1 1- [�,17— T^Printed Name of Funeral Director Signature of Funeral DyKj4r Date or Undertaker or Undertaker 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 F6reoa Making Disposition Signature Date #9 WHrrfl:Funeml Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET 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 reprent that I/we have full legal right and authority to authorize the cremation,processing and disposition of the remains of /{�0 r�� (' (hereinafter referred to as the`Deceased'). Name of Deceased Date of Death /-q Time of Death AM. ❑P.M. I/We hereby request and authorize IiL C;A 4 =Atd( (hereinafter referred to as the"Funeral Home")to Name of Funeral Home _ take possession of and"arrangements for the cremation of the remains of the Deceased at IINL VIC N1 C,Q M A 0Ly (hereinafter referred to as the"Crematory"). Name of Crematory Me authorize the Crematory to return the cremated remains of the Deceased to the possession and custodyof the Funeral Home. I/we understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of theDeceased 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 91 No Describe Description of urn or container selected: (_ IZD► del 1<.D {�!C Suitable for shipping: &Yes ❑No 91 Deliver to S l. M A P,,Y 15 C CNl C TTC IzY 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 ❑ 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, recessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws, e rules, regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: I. 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. a casket or other container constructed of metal, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Decea ..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 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 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 EU 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 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 r irreversibly destroyed by prolonged exposure to intense heat and direct fume. 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,jewehy 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 eonsisteneu 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 _111 1 1 . 1 t 1 . .1 r 1 Tr _ ._._il--_--,I- it--------"----- ----_`_�_-_ .