Dier, Mary TO'74N OF QUEEN
.s5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l( � C
P
Name Case #
Date of Crematicn —6;4
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Time Cremation Started � /' �'1�
Time Cremation Completed ';� 1<7Q / "Al P
Type of Container
Remarks :
A1,41 N 90,VNIG-9 014
' TOWN OF UUEEN88URY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 7745444�bor if no answer
Cemetery
AUTHORIZATION TO CREMATE
in
The rdanceigwithrandeSts and subjectauto° its , ping Rules View Cremator
and Regulations' to
accordance
cremate the remains oft
tNaMe
(SON)
(Street ) (City) (State) (Zip Code)
who died on
c a day of 1922
�
at d (Address)
(Place)
Name and address of nearest living relative or name of , person
authorizing cremationt
• / —
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMpORTANTs wled a the deceased has or
kno
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
ion Of
for the cremation of the remains ersonal to dipossesSiang rect the shave(either
the cremated remains, that any p rotect, defend
been removed or may be destroyed, and agree to P
e View Crematorium from any and all claims
and save harmless Pin
which may be made against then by
and demands for loss or damages w
o o said
reason of whethernsuchins 89
dclaims or with e demands areorar a
or e not wholly
directed,
groundless, false or fraudulent.
O 2-"
(Ad ressl
/ ignature of Relative or Legal Rep. and Address)
Signed on this date $ 2
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cram :e
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 Vrew `
Crematorium from any and all claime 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 .
PG'Z'�C
^ vq�y AUTHORIZATION FOR CREMATION AND DISPOSITION 03IRev.4/98
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
_ CRE TIO. IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CARPKI LY 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 &do 0* T
(hereinafter referred to as the"Deceased"). Name of ase
Date of Death j" Z Z Ef9 Time of Death a ❑ A.M. KP.M.
I/We AfFeby request and authorize (hereinafter referred to as the "Funeral Home")to take
0 ome f
posseman of and make arrangements for a cremation of the rem . of the Deceased at
(herei4fter 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 handling required? ❑Yes $e"No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to �,.ctA. .0 / �� /Z S'YJ Cemetery
ame an s o em
❑ Release to family
ameo amp em r to ecerve rema emams
❑ 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 gW rning 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 an 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 ❑ 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
Descripttap-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
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 beceased,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
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. 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 be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is
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