Liapes, Nichoals "IOWN OF QUEE9\(*v5BU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � r-&)C) N D L N N
Name H1 cAy }q -'; ?. �'% ri 'Pe""2 Case # A/ / /
Date of Cremation 3 o - 99
Time Cremation Started !I -"l V �' y \ ! �
Time Cremation Completed l 1�660 1 2:fA o [�
Type of Container %A-�Z- CJ 1-3O1t\7_-d &cjNY / y' C�(`j�` c�� � 4t)
Remarks :
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TOWN OF ❑UEENSBURY
i PINE VIEW CEMETERY
+ice
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
------ `"--' Cemetery 745-4476
----' AUTHORIZATION TO CREMATE
The unders,igped requests and authorizes Pine View Crematorium, in
a6cordance with and subject to its Rules and Regulations to
cremate the remains of :
-- Nt C Spa 1,NC ,- t A PyS
Asciw b ati':` -1 (Namtr') (Sex)
,aybbnu2
Yd ajrt _� n GO! �Q s\ QL)C6r%kSec12.t/
(Street ) f (City) (State) ( Zip Code)
9niq s.fwho sdded on �-( 111 day of '600U-S1 19—at i J WEWCo A 5T CA') t-n«'3y(2'y
n 1 (Place) (Address)
9vbri
Name and address of nearest living relative or name of person
authorizing cremation :
CA(?4J.. ,LiA06S /1 Al v1lGori (,3 66LAIS 93 4)rZy i.t,
(Name) (Address) T-
Relationship to the deceased WIF E _
Name of Funeral Home �SUJ-LIVltn( Nt[A(l}lfl�(� 2166
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 )
(Signature of Relative or Legal Rep. and Address)
f'
Signed on this date :
M
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 Sur,uays,
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 -4nd 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 $ 185. 00
Children (age 13 months to 12 years ) $ 11.0. 00 Infants ( stillborn
to 12 months) s�0. 00
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation:
7
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains:
❑ Burial at L-Return to Family
_ a
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated,Remains and,acknowledge receipt of a copy of
"diis form.
(Signature)
(Printed Name) 2 i (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 placement in a columbarium."
Printed Name of Funeral Director Signature of F"eA 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
I
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSDUEN Rev.V96
I
O`
ZATION FOR CREMATION AND DISFOSITION 031Rev.08
WAL1)OCCUMENI:IT CpNTAIN" ORTANT PROVISIONS CONCERNING CREMATION.
• ERSIBLE AND FINAL.READ' S DOCUMENT CAREFULLY BEFORE SIGNING.
epceaent.thatJ/We have the full legal right and authority,and know of no living person who has a superior
atfo anddbsi. ttm of the remams of Processing .
Name of DeCeSM
Date of Death a'I l 199
Time of Death Co 3 o G� A.M. ❑P.M.
_.._ j„L1 VR q fel fAIA W ftt /_ (hereinafter referred to as the `Funeral Home")to take
Werremation of the remahisafthe Deceasedat I�1/Jl:WC VJ 612 r kA l c(hertz to as: " _"' 18PI).
anxrematary
I/We hereby`auttiorize ' ary to return the cremated remains of-the deceased to the possession and custody of the Funeral Home.
I/We understand that obligations of the Crematory shallhe ft�IBlled when the cremated remains of the deceased are returned to the
possession slid custody of t Home I/We hereby authorize the ttneral Home to arrange for the disposition of the cremated remains of the
Deceased as follows: `
Is special handling �'C�1 No Describe
-----Description of selected: a_ Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Ceinda•y
. lease tofauW } `�a O 1, L IA PCS
ve e
.��7�- nn at�ea b�-=Funeral Home or mineral Home's a
❑ Ship via..�'�'�•. Marls
To:Name A
sCrematory are not responsible fbrang 16M or damage of cremated remains shipped via Registered Mail with the United States
sin and disposition of the remains of the Decease¢authorized herein shall be performed in accordance with
regulations and policies of the Cremdtory and Funeral Home,and the following terms and conditions.-
ins of the Deceased will not be acceptet for" n unless received by the Crematory in a combustible, leak
cremation container.The Crematory i9 61horized to remove and-dispose of handles,ornaments and any other
b imli items attached to the cremation contatW:p�rw to cremation.In the event the remains of the Deceased are
receI red-bythe Crematory in a casket or other c Wucted of metal,fiberglass,or other noncombustible materials,
wive autharize�the_Temains of the Deceased to be to cremation and placed in a combustible cremation container.
We fu3rther 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
wh+ra-.placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of
itn acted mechanical.or radioactive device. In the event the-,remains of the Deceased contain such a device Vwe hereby
an oa ize 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 HEREB� EtTIFY. _
-- .
., PLANTED 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 disposeat as indicated:
Dem iption d Implanted Device DbpuM-
7
DeaoriP"aP ImPlanted Device Di tioa
. .
tfuction for-disposition is given, cl�i-iitems ntt_ be disposedf at t discretion,q. the FuneralHome.
- ation container containing a remains of Tne jueceaseu Win SelplaceMn twe c e
destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cremation
wA ng the cremation process and reposition the. ains of the Deceased in order to facilitate a complete and thorough
Y =_ items,including,but not limited to body prostheses,-dentures,dental bridgework,dental filling �ewelry,and other personal
'articles accompanying the remains of the beceased,may-fie toyed during the cremation process.I/We further authorize that if
any items,other than the cremated remains of the a_f recovered from the cremation chamber,they may be separated
Y. from the cremated remains of the Deceased and disposed of -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,consisEkng primarily of bone fragments,w111 be mechanically pulverized
to an unidentifiable consistency prior to placement in an urn or mar container.
7: Unless an urn or-container.;able for ' ment is purchased,the Crematory will place the cremated remains of the Deceased in a
oil r
8. In the event the urn or container Is rasa elen a a ail
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or con amer.
4 I/We understand and acknowledge.that even with the ezer4seAtstagan4ble care and the use of the Crematory's best eff ts,it is