Aldous, Jessica TORN OF QUEENSB`LlP.,y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name V 5s/(i'd�j`./.U'!/� C a s e # -3-3�
Date of Crematicn
Time Cremation Started
t
Time Cremation Completed
Type of Container ..3 57�J
Remarks :
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TOM OF UUEEN9BURY
p1W VIEW CEMETERY
R
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 774544776or if no answer
Cemetery
AUTHORIZATION TO CREMATE
The accordance
withrandeSsubjects and autooitsds Pint Rules View and Regulations' in
to
accordance with
cremate the remains oft \�
(Sem)
G-� `n Code
(Street) (City) t ate) (Zip
� 19
who died on 6 -day of
" G.
at (Place) (Addy ss)
Name and address of nearest living relatiVe or name of person
authorizing cremation!
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: knowled a the deceased ha• or
ent that to the bestof MY (Circle One)
1�75
acemaker in his or her body.
full
autho
iion to
ge
I certify that I have the re
power and tod r
directthetdispositionnOf
for the cremation of the remn� sonal possessions have either
the cremated remains, that any per to Protect, defend
been removed or may be destroyed, and agree
and save harmless ;:nor damages view ewhichium mayfbeamade againstany and ltheaibY
and demands for to
ins as
reason of or connected
claims orthe
cre deaandsoareoorsaare not awholly
directed, whether
such groundless+ false or fraudulent.
(Witness) (Address)
of Relat ve or Legal Rep. and Address)
(Signature
Signed on this date !
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.
d
"Customer's Designation of Intentions'?
Name of Deceased:
Cremation: 4
(9�ednled Date) (Location)
Manner of Disposition of Created Remains:
Burial at El Return to Family
Ei Entombment at i D Other (spec*):
i"by designate the Disposition of Cremated Remains and admowledge receipt of a copy of
flue form.
(Signatl—)
Ca ot r
(Printed Nam (Mtionahip3k.Deceased)
(Add.00)
(Weph.—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 e of Funeral Director S*L -of Funeral Director Dit,
jr Undertaker �11--Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(A,ctu,I'IDate) (Location of Crematory)
Disposition of Cremated Re7a*ms: (Manner of Deposition)
(Location)
(Date)
Name of 16raon Me Signature Date
"
#9 WHITE:Funeral H.COPY YELLOW Family cow PINK:Crematory Copy CUSINTEN Rev.Q96
C&A,
�¢ 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 know of no.living personii who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of ZrE',-I C G, ill dI�.LS
(hereinafter referred to as the"Deceased"). Name of
ii Date of Death Time of Death �. A.M. El P.M.
I/We hereby request and authoriz 1\� (hereinafter referred to as the "Funeral Home")to take
Name off,uneral Home
possession of and make arrangements for the cremation of the remains of the Deceased at
(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-*'d No Describe
Description of urn or container selected: 1-6' Suitable for shipping: Yes ❑ No
Deliver to Cemetery SL ame an ress o eme ry
❑ Release to family
Name of Designatedamp y Member to Receive Cremated Remams
❑ 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 oFthe Deceased
prior to cremation, and dispos of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT�ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Pleaselnitial 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
Description of Implanted Device Disposition
._Ifuo 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,* welry,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 best efforts,it is