Parlin, Joan L O i' Y N OF QUEEN4r5BUP*,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name :�IAA /�I/& /'► Case #t
Date of Cremat i cn Z
Time Cremation Started ?","
f
Time Cremation Completed
Type of Container 0,2o12
Remarks :
� ��`19 tv-1
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
1,42\f ����i A/ I L=9Y
(Name) (Sex)
(Street ) (City) (State) (ZipCode)
who died on /� � day of a y 19 _
at_ t.N S l�A.�..�5 /�OS(J� A.�.
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
nUA12j s 06aj.,d p�E����, c �. ��� sILt�t;2
(Name) (Address)
Relationship to the deceased ,)-If1S13i LA
^r ` '
Name of Funeral Home 12L CAN 41 !�(=/ AI)�
IMPORTANT:
I represent that to . the best of my knowledge, the deceased hoo 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
groundlessg false or fraudulent.
I
(Witness) (Address)
(Signature of Relative or Legal R and Address)
c.
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
containe=. 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 .
�, 4w AUTHORIZATION FOR O TION AND DISPOSITION 03IRev.08
C�/
•" NOTIC :THIS IS A LEGAL DOCUMENT.IT CONTAMS I 'ARTANT PROVISIONS CONCERNING,CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that I/we have the full legal right and authority,and of no living person who has a superior
priority right understate law,to authorize the cremation,processing and of the remains of C'/i 1\1 PA fG I-hv
(hereinafter referred to as the`Deceased'). / aM Of DeCOFAW
.r} Date of Dean- f/, 7 Time of Death 3 i 30 ❑ A.M. iK P.M.
I(We hereby request and authorize ►if At 4' 06 (hereinafter referred to as the "Funeral Home")to take
Jr of and make arrangements for the cremation of the remains of the Deceased at /,Plt nl[.;V 1 6 Vw/
(herekofter referred to as the"Crematory"). Now of Cmmtwy
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 Creory shall be..fialfllled when the cremated remains of the deceased are returned to the
and custody of the Funeral Homo.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
40 hallows:
Issue - required? ❑Yes [A No Describe
of urn or container selected: Suitable for shipping: Yes ❑No
❑ Deaver to Cemetery
_Release to family It M6 tt k yl 1 *14RA. 1^1
❑ ScaRering at sea by Funeral Home or Funeral Home's agent
❑ via U.S.Registered Mail*
`IW Name Address
❑ cow
*Funeral Rom and.Crematory are not responsible for-any loss or dam remains shipped via Registered Mall with the U
Pea Service.
The cremation,processing simd disposition of the remains of the Deceased authorized herein shall be performed in accordance wig
all governing laws,the runes,regulations and palicies of Cremid , ,and Funeral Home,and the fs► o ving ter nA nqA'
1. The remains of the Deceased will not be_aecepbed.for cremation-unless received by the Crematory in w-comb
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and
noncombustible items attached to the cremation container prior to cremation.In the event the remains of the I e,e
received by the Crematory-in a casket or other container constructed of metal,fiberglass,or other noncombustible m
Uwe authorize the remains of the Deceased, o.be removed prior to cremation and placed in a combustible crema '
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket" "
manner it deems appropriate. s
2. Mechanical or radioactive devices implanted in the remains of the Deceased(such as pacemakers,etc.)may
when placed in.the cremation chamber. The Crematory will.not cremate any human remains which c _
implanted mechanical or radioactive device.In the event the remains of the Deceased contain suck a
authorize the Funeral Home,its agents and employ Iees,to remove any_such mechanical devices from the r.
prior fro cremation,and dispose such items at its discretion. /WE HEREBY CERTIFY THAT'1'HH; F T
DCCEASED DO ❑ DO NOT VXONTAIN ANYTYPEOFfMPLANTED MECHANICAL OR RA>!B I EYICE.
Please initial one.
Listed below are all implanted mechanical and radioactive 4evices which the Funeral Home is authori
r .rei Y inthe
remains of the Deceased prior to cremation,and dispos oaf_ indicated: .yti
_�ss
Dew*dm of h*bted Device
Diepoaitl00 r
Dawipflm of Impmnted Device DLpodd- �.
3. The cremation container containingg the remains of.the Deceased will be placed in the cremation chain aAnd will be totally and
irreversiblydestroyed by prolongedexposure to intense heat:and direct flame.I/We authorize the C " fo'o ffilCi a mation
chamber during the cremation process and reposition the remains of the Deceased in order to facftati� y pi e a �orough
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillin ems`�,and ofer . rsonal
articles accQ_mean ' g the remains of the Neceased,maybe destroyed duringthe cremation process. er_ -that if
an other. the cremated remains of the:Deceased,are recove from the cremation chaos Grated
y items: than nd, • .�` .-,._r
from the tamed remains of the Deceased and disposed of by the Crematory. F.
S. I/We hereby,authorize the Crematory to separate and remove from the cremation chamber all noncombus ' ,including,
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
6. FolIowing cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be v#ri nd
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
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
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn
9. I/We understand and acknowledge,that even with the exercise-of reasonable care and the use of the Crematory's btR,
REGAIN & DENNY FUNERAL SERVI(M
53 Quaker Road
Queensbury,Now York 12804 •
(518)792-1114
"Customer's Designation of Intentions"
Name of Deceased: -AC A t,
v R,
Cremation: �,-li I&j ic
(Scheduled Date) (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 acknowledge receipt of a copy of
this form.
CXA,
(Signature)
-1 8 A,(Printed Name) (Relationship to Deceased)
IAA-{/ni
(Address)
(Telephone N-nher)
"Cremated Remains which shall not have been claimed within 120 days from thedate-of
cremation may be disposed of by this firm by placement in a columbarium."
'Printed Name of Funeral Director Signature of S...r5VPirector 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 Cow YELLOW:Family Copy PINK Crematory Copy CUSUMN Rev.4096