Harris,William TORN OF QUEEN,5BU-I � '
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director
Name �' r1' i� � e �(�jCase #� �h�
Date of Cremat i cn 1
Time Cremation Started
Time Cremation Completed U 4,A
Type of Container
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Remarks : Gt CP%SQ V
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TOW OF UUEEN9BURY
PINE VIEW CEMETERY
ICREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
f Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and autho(^ize3 Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft
RK \
(Name) (SON)
u 1 C 6 i bl 004 0
(Street ) (City) (St at el (Zip Code)
who died on day of �G�J / 19
at (214=;rIVs 1 ���
(Place) (Address)
Name and address of nearest living relative or name of pertori
authorizing cremationt
0- IkP)\S Rrr AO;5,- Zd2z�
(Name) (Address) y
Relationship to the deceased W C ��
Name of Funeral Home J/
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, Nether such claims or demands are or are not wholly
gr ndless, als or rah ulent.
(Witness) Address) /
(Signature of Relative or Legal Rep. d A dress)
Signed on this dater12 C a
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.
„Customer's Designation of Intentions”
Name of Deceased:.
Cremation: o ,
(Scheduled-D4.) (Location)
Manner of Disposition of Cremated Remains:
El Burial at Return to Family
El Entombment at El Other (specify):
i hereby designate the Disposition of Cremated Remains and acitnowledge receipt of a copy of
tins form.
(Sign-t!3-)
-j
(Printed Na (Relationship to Deceased)
ol fit)
(Address r
V -S
(Telephone Number)
"Cremated Remains which shall not leave been claimed within 120 days from the date of
cfpmation may be disp sed of by this form by pliopment in al *mbarium.L, 1"9
Printed Name of Funeral Director Signature of Funeral Director 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 Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSDIMN Rev.4/96
boo q� AUTHORIZATION FOR CREMATION AND DISPOSITION 03lRev.4/98
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,warrant and represent that Uwe have the full legal right and authority,and now o l�g pei�pa,wh
priority right under state law,to authorize the cremation,processing and disposition of the remains of f�� I'1
(hereinafter referred to as the"Deceased"). ame o eceasea
r /
Date of eat . Time of Death !• A.M. ❑ P.M.
I/We hereby request and authorize / (hereinafte referred to as t " uneral Home" take
possession of and make arrangements for the cremation of the remains of the Deceased at F-^10L.,,
(hereinafter referred to as the"Crematory"). ame o 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 handling required.' ❑ Yes �kNo Describe
Description of urn or container selected: Suitable for shipping: Yes ❑No
❑ Deliver to
ame an rasa o eme ry
Cemetery
.Release to famil f
Name o ig'a son y em r to Receive CrmematedRemains
❑ 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 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 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 of the Deceased
prior to cremation, and dispose f such items at its discretion. I/WE 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 A
Description of Implanted Device
P� P Disposition
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home.P g � Y P
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally ti
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the crap
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and y
cremation.
4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings,jewelry,and other p
articles accompanying the remains of the eceased,may be destroyed during the cremation process.I e further authorize
any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be se
from the cremated remains of the Deceased and disposed of by the Crematory. ,x:;
5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials t m4
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. r'
6. Followingg cremation,the cremated remains of the Deceased,eertsi Iy e€beae fragments,will be me
to an unidentiflable consistencyprior to placement in an urn 61r other container.
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the
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'
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or coatamee ,