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Scheider, George 70� � OF QUEEN,5BU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director &ad Name . gbk;� Case # � t7 / Date of Cremation O J Time Cremation Started ✓`� F�1 ' Time Cremation Completed Type of Container 419-,12 Z?-eJ-X Remarks : // !/ 1© �` .38 TOWN OF OUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) 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: ( me) (Sem) (Street ) (City) ( (ate) (Zip Code) who died on 1/ day of 199 at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: (Name) (Address) / Relationship to the deceased G1'� Name of Funeral Home-77 IMPORTANTs I represent that to . the best of my knowledge, the deceased has or a 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 boon 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, f Ise or fraudulent. (W ness) (Address) (Signature C9 f Relative or Legal Rep. and. Address) Signed on this date : f 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 . r • 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 AUTHORIZATION FOR CREMATION AND DISPOSITION 03lRev.JIM NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS MWORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.R.EAl1 TAIS DOCUMENT-CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,warrant and represent that Uwe have the right and authority,and know of no living person who has a superior priority right under state law,to authorize the cremation,processing autd4ftitkin of the remains of C SAC h (herelaafter referred to as the"De eased'l. k _ Date of Death Time of Death ❑ A.M. ❑ P.M. I/We hereby request and authorize '+ .0 wt= (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remahwof the Deck at (hereinafter referred to as the"Crematory'l. Nameacnanatory I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home. I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the possession and custody of the Fungal Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Uspeclillh required' ❑Yes S6 No Describe Description of urn or eontahur selected: Suitable for shipping: ❑ Yes ❑No ❑ Deliver to Cemetery mmmcry -�Release tafanu7y rGst�-� ,��-:,e.�-+�,_ Name orDedpated �m Receive reins ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S.Reed Mail' To:Name Address ❑.Other 'FVneral Mow=Crematory are not responsible for any 1om or cremated remains shipped via Registered Mail with the United States _l 1?fa�i'Service. The creumWon,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,riggid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and any other noncombusfible 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. Me further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it tteems 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 Vwe hereby drize 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 st Us ;ran. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO ElDO N0T CONTAIN ANYiiWj IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all impl nted.mechanical and radioactive deices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of�Windicated: Description of Implanted Device Disposition TO 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 containwg 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�ewelry,and other personal articles accompanying the remains of the Nceased,may be destroyed dur€n the cremation process.We further authorize that if any items,other than the cremated remains of the Deceased,are recovered gfrom 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. Foflow- crenadoa,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverized to an um ent€flable 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 remainsmiil be placed in a secondary container and returaeei to,the Funeral Home,together with the primary urn or container. 9. VWe understand and acknowledge.that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is PUti~ �� qw AUTHORIZATION FOR CREMATION AND DISPOSITION 03IRev.4M NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNINUCREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living person who has a superior priority right understate law,to authorize the cremation,processing and disposition of the remains of (hereinafter referred to as the"Deceased"). Nam of Date of Death Time of Death ❑ A.M. ❑ P.M. I/We hereby request and authorize /' . ... 1 rl' .e_,, - (hereinafter referred to as the "Funeral Home")to take on of and make arrangements for the cremation of the remains o the Deceased at possession g (hereinafter referred to as the"Crematory'). Name of rematory I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home. I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased 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 I ndling required?- ❑Yes 9 No Describe •A Description of urn or contained selected: . Suitable for shipping: ❑ Yes ❑No ❑ Deliver to Cemetery _s +� amY J Release to family 4� Z,,;r,'::. :.• .,_ sane oF Designated Family Member 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 Rome 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 auth rize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container. f I/We furtr authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful f 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 ott 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 A CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. °. isted below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the VI—mains of the Deceased prior to cremation,and dispose of as indicated: Description of implanted Device -- — -Disposition- - .;..,. -- ..,..... ... ........:��.e.,.,'tea` -• - ..�-.e....:.. ... ..- " ., ..w.-«�._.,. .�— ?:s�•:.�.�.:. Description of Implanted Device D�ositioa - :i v If no instruction for disposition is given,such items may be dJsposed of at t`hib 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 reversibly 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 hi order to facilitate a complete and thorough cremation. 4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillin s ewelry,and other personal articles accompanying the remains of the beceased,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 gremation chamber all noncombustible materials,including, but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of�uch materials. 6. Following cremation,the cremated remains of the Deceased,consisting primarily of bongfragments,will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other co tainer. N7. Unless an urn or container suitable for shipment is purchased,the CremaTpry 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�emated remains of the Deceased,any excess cremated remains will be placed in a secondary container and returned to the Funerai Home,together with the primary urn or container. 9. I/We understand and acknowledge,that even with the exercise of reasonablq care and the use of the Crematory's best efforts,it is "Customer's Designation of Intentions" Name of Deceased: . 1 Cremation: (Scheduled Date) (Location) Manner of Disposition of Cremated. Remains: ❑ Burial at E5 Return to Family ❑ Entombment at ❑ Other (specify): I herehy designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of this form. (Signature) :1 (Printed Name) (Relationship to Deceased) (Address) f• (Telephone Numher) "Cremated. Remains which shall not have been claimed. within 120 days from the date of cremation may he disposed of by this firm by placement in a columbarium." Printed Name of Funeral Director Signature of Funeral Director Date or Undertaker or Undertaker HOUR TO BE COMPLETED FOLLOWING CREMATION AND DISPOSMON OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW Family Copy PINK.Crematory Copy CUSINTEN Rev.V96