Whible, Augustus uYJSs.aL_f. ........
T094N OF QUEEVBU-�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
F u n e r a 1 D i r e c t or /f ���
Name il�_-���,
Date of Cremation , /
Time Cremation Start ed // i c�'
Time Cremation Completed
Type of Container
Remarks:
OX
dzm
A/I '
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
' CREMATION IS IIi'REVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE-SIGNING
I/We,the undersigned, certi{y,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o A;_��,{'.5 l i.`, S1/(f! �L t: S! (hereinafter referred o as the"Deceased").
Name D
Date of Death_ . J�;y` 7 i Tune of Death ❑An ❑PM.
I/We hereby request and authorize r2c-CA,&r f DEAlhl (hereinafter referred to as the"Funeral Home")to
Name Funer H me
tape possession of and make arrangements for the cremation of the remains of the Deceased at /Ji 4 yic y,(
(hereinafter referred to as the "Crematory"). Name of Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral returned to
C t hall he
theunderstand that the s dy and e Funeral Hoons fme.e.eI/W hereby authoorrizeetthlleFuneral ome on the ted remain,ar arrange for t}the he disppositiond are of the cremated
the possession and Gusto 0
remains of the Deceased as follows:
Is special handling required? ❑Yes 9 No Describe
Description of um or container selected: Suitable for shipping: &Yes ❑No
® Deliver to _`�c t,t ►- t= C, - M 0 1 C: Cemetery
Name and Address of Cemetery
El Release to family
Name of Designated Family Member to Receive Cremated Remains
❑ 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
ocessing and
sposition of
remains of
governing aws,,Z rules regulations and policies of the Crematoryeand Deceased authorized
Home,ea herein the follo shall
bg performed s nd c conditions:
with all
1. The remains of the Deceased will not he 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 noncumhustible 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 of the Deceased
prior to cremation, and dispose of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 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 he disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will he 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, jewelry, and other
personal articles accompanying the remains of the Deceased, may he destroyed during the cremation process. I/We 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 hone fragments, will he mechanically pulverized to
an unidentifiable consistency prior to placement in an um or other container.
7. Unless an um or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in
a container which is not designed for any type of shipment.
8. In the event the um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
a
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, 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:
AA J-:S i",S V\!<tW 'U' AIL
(Name) (Se►c)
(Street ) (City) (State) ( ip Code)
who died on ;2 day of 19
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
S'' ;U i VAt\1 jD
(Name) (Address)
Relationship to the deceased
Name of Funeral Home JC1GL(tf� J� C'/��V y
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 damagesA 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, f'�lse or fraudulent.
(Witness) (Address)
Sig " ture of Relative or//Legal Rep. and Address)
Signed on this date : Zr 3 ( `1