Hockenberry, Lastat TOWN OF" QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case # � ,
Date of Crematicn_g — sz-72
Time Cremation Started-1/!q/y/ Od I
Time Cremation Completed /a/
Type of Container iJ#jT G,(�s7i/ GI�s1 ZT �/ D,
Remarks :
11 11
1� 11
TOWN OF QUEENSHURY
PINE VIEW CEMETERY
CREMPTORIUM
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:
k4;�+Ck+ 6 .
(Name) (Sex)
35 0 WWr 4_0dSffi 1"6AOS C ±
(Street ) -61 (City) (St te) (Zip Code)
who died on CX? b day of 19q9
r
at P 4X tD+1J J 0
(Place) (Add ess)
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Address)
Relationship to the deceased rn 044r
Name of Funeral Home G-
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
groundless, false or fraudulent.
(Witness) (Address)
(Sig ture of Relative o egal Rep. and- Address)
Signed on this date :
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
reiWins 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 .
ATION FOR CR,JATION AND DISPOSITION
031Rev.4/98
DOCUMENT.IT CONTAJNS 9*90WANT PROVISIONS CO
NCER(VING CREMATION.
MA VERS1BLEAND FINAL.READTHIS DOCUMENT CAREFULLY BEFORE SIGNING.
" rprrant,and represent that Uwe have the fuller right and authority, know f—no li ' who ha superior
K' --
r „ authorize the crematian,prong and .. of 117crq
remains of t' C r
the�� ;�• N
Date of I#esth Time of Death 'Y A.M. P.M.
_ (he matter to the ° Home l to take
is for the cremation of there the Deceased at J M
4'Clematoryll. ame Wry
_- + the Cr-ematory to return the cremated remains of the deceased to the possession and custody of the uneral Home.
and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the
t>ae Funeral Home.UWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
{- r 2 .❑Yes No Describe
l- n or,cofit9bw selected: Suitable for shiPPiug. Yes ❑No
4.
_ toW. Cemetery,,,-�.'. mce m ve e
_ s
Name Address
❑ ..,..
meand Crematory are not responsible 1k any loss or dee of cremated remains shipped via Registered ail with the United States. .
s;fih>e emotion,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with
all goys laws,grin
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,ar' id 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,
Uwe authorize the remains of the Deceased-to be removed prior to cremation and placed in a combustible cremation container.
UWe 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
i nted mechanical or radioactive device. In-the event the remains of the Deceased contain such a device Uwe hereby
au prize 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 discretigjL 1/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT ❑CONTAIN ANY TYPkOF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
be1, mplanted mechanical and,radioactive devws-which the Funeral Home is authorized to remove from the
ed prior to cremation,and dispose of as indicated:
Dwr"Wef1mph*WDevke )
n,
.-.
If no instruction for disposition is given,such items maybe disposed of at t e discretion of the l uneraC T ome.
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
nduring the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough
4. Certain items,including but not limited to body,prostheses,-dentures,dental bridgework,dental fillings,*ewelry,and other personal
articles accompanying to remains of the�eeeased,may be destroyed during the cremation process.UWe further authorize that if
any items,other than the cremated remains of the-Deceased,are recovered from the cremation chamber,they may be separated
the cremated remains of the Deceased and disposed of by the Crematory.
5. UWe 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 designated 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
remains will bye placed in a secondary container and returner Wthe Funeral Home,together with the primary urn or container.
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RE 'AN& DENNY FUiNERAL. SERVICE
53 QuWm Road
w-T. a- .. Qwvs xgy,Now Yofk 12804 ar
(518)792-1114
"Customer's Designation of Intentions"
Name of Dece ed• {,
Cremation: p r ,� c/
(Scheduled Date) (Location) Y
x
Manner of Disposition of Cremated Remains: "
❑ Burial at Return to Family "
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and ac6mwledge receipt of a copy of
this form.
(Signature)
-_ &n ►-t
(Printed Name i lationehip to Deceased)
( ,...
(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 placement in a columbarium."
Printed N me of Funeral Director Sign of Funeral Director D e
or Undertalzer 6r Undertalter
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 Pierson Making Disposition Signature Date
*9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSHMN Rev.9096