Costanza, Genevieve TOWN OF QUEENs5BUP.,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6:7 /V
Name l P' �// 6�'"f� G a s e # T2
Date of Crematicn
Time Cremation Started
Time Cremation Completed 6 c?'! 40 8 )
Type of Container Zk
Remarks :
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JUL-11-H SUN 10:00 AM SIiNGLETON HEALY FUNERAL FA' NO, �187983641 p 1
TOWN OF q(J NEpIJgr
PINE VIEW CEMETERY
CREMATOR 111M
ouaker Road4 pueensbury, New York 12904
Phone (5181 crematorium 145-4417 or !f no answer
CemsterV 745-4476
AUTHORIZATION TO CREMATE
Crsma
authorises Pin• View tsorims In
with and subject t:a its Rules and Regulations to
The undersigned re4uetts and
_
c •Mato the remains vFs
MIX?
�U IX
Mt T" I CCC��` t� •te) t 1p ,Codt►
15treet) 1C11Y) ./
day of
who died
-G lee �—��
at (Add sss
/Place) rrtvn
Name and address of nearest living relative Or naMe of p
•uthcrtein9 cremstion+
co�qf��L �
(Name)
1pddrsss)
to the deceased
Relationship dsceast r--
Nows of Funeral Ndme
Hnowlediie, the decMased has or
IMIPOgT slot that to the best of sY (Circle One)
has no l�acewaker in his or her body•
/ wsr and authorisation to arrange
s full power disposition
I certifY that I have th either
that any Personal pessesslons have defend
the cremation of the
remains and to direct e
for remains. agree to protsctI
the cremated be dsstroyeds and ap any and all claims
bean removed o+^ nay View Crematorium fro+�mads against them by
and save harmless is ordamages which may or remains as
and demands for loss the cremation of said wholly
o son of r connected with
readirson
whether such laim nt�
groundless, r demands are or
reaere no
false or
inddrees)
(witness)
r
ve or Legal Rep. and Address)
(Signature of Rel
Signed on this date' `11 /
I
03lRev.4/98
AUTHORIZATION FOR CREMATION'AND DISPOSITION
T IS IS 4LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONC RNING CREMATION.
T
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,anp-know of no living per who superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name o eceasV,tCJ1Jed L 1
(hereinafter referred to as the"Deceased"). � A.M. P.M.
Date of Death � ICA Time of Death
I/We hereby request and authorize D a-n (hereiqafor referred to as the "Funeral Home")to take
amen une o
possession of and make arrangements for the cremation of the remains t Deceased at ame o remarry
Wiffer referred to as the""C1V f ff6ry'1.
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 Cemetery
ame an Tess o eme ry
❑ Release to family
Name of DesignatedFamily member to Receive Cremated Kentains
❑ 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 dT 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 ofzthe 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
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 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.I/le 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.
S. 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
REGAN &DENNY FUNERAL SERVIM--"4--"
53 Quaker Road
Owmbwy,New lork 12804
(518)792-1114
"Customer's Designation of Intentions"
Name of Dekea-
1 ,4 V�(, k-
Cremation: (Scheduled Date) (Location)
%anner of Disposition of Cremated Remains:
J
0 Burial at 0 Return to Family
F-I Entombment at ArOther (specify):
i hereby designate the Disposition of Cremated Remains and acItnowleage receipt of a copy of
this form.
ure
CWz"`. 4�--As
(Relationship to Deceased)(Printed Name)
ytl
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be dis7sed of by this firm by placement in a columbarium.
Printed Nt Director Sign of Funeral Director Dake
U
or Unaertalter
TO BE COMPLETED FOIJ.OWWG CREMATION AND DISPOSMON OF CREMATED REMAR"-
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains: - Manner of Disposition)
(Location)
(Date)
Name of Berson Me"Disposition Signature Date
#9 WHffE:Fune.1 Home Copy YEUDW.Am*copy PINK:Crematory COPY CUSHMN Rev.4/96