Lykens, Ruth 70 q+N OF QUEEVBURY
PINE VIEW CEMETERYY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funera 1 D i rect or ) ��)
Name Tfi Case # ��%
Date of Cremation
Time Cremation Started
Time Cremation Completed, 44 &
Type of Container L / (5~/ ( � ? L /1 > (J
Remarks:
. TOWN OF OUEENSBURY �/6
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12904
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 oft
(Name) (Sex)
(Street ) (City) (State) (Zip Code)
who died on J I day of
at Q
(Place) (Address)
Name and address of nearest living relative or name of , person
authorizing cremations
(Name) (Address)
Relationship to the deceased
r /mil_ 9�
Name of Funeral Home
IMPORTANT:
I re went that to the best of my the deceased has or
knowledge,
. has no-pacemaker in his or her body. (Circle One)
I certify that 1 have the full power and authorization to arrange
for the cremation of the remains and to direct
possessionsshaveteither
ion Of
the cremated remains, that any personal
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.
tness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this dates
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.
XBOOKLET
AU MORI TION FOR CREMATION AND DISPOSITION
CE:THIS IS A LEGAL D CUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATI _ S I EVERSIB E AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SI'GWING'�gned, ce ,warrant and resent tha I/we have the full legal right and authority to authorize the creation,processing and
spostonote remains o (hereinafter referred
to as the"Deceased„).
Name o Deceased
Date of Death 7/ Time of Death ❑AM. ❑PM.
I/We hereby request and authorize (hereinafter referred to as the"Funeral Home")to
Nameo Fune Home
take possession of and maize arrangements for the creation of the remains of the Deceased at �,'i,��,,
(hereinafter referred to as the"Crematory")• Name of Crematory
I/We authorize the Crematory to return the created remains of the Deceased to the possession and custod remains of the Funeral Home. I/we
ations of the Crematory
fuu* ed when the
to
the possession understand
n and custody of the Funeral Home. I/We heeb s�or e Funeral om o as nge for the dispositiond are of the cremated
ed
p y y authorize th
remains of the Deceased as follows:
Is special handling required? ❑Yes JU-No Describe
Description of um or container selected: Suitable for shipping: ❑Yes ❑No
Deliver to d. Z i�,,.� ,,1 Cemetery
Name and Address of Cemetery
❑ Release to family
Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Homes agent
❑ Ship via U.S. Registered Mail*
To: Name: Address:
❑ Other
Funeral Home and Crematory are not responsible for any loss or damage of created remains shipped via Registered Mail with the United
States Postal Service.
The
shall
governing laws,/the rules,regula g and disposition
and policies of the Cre atory the
and FuneDeceased
ral Home,authorized
aandherein
followinbg performed s d condition: with all
1. The remains of the Deceased will not be accepted for creation unless received by the Crematory in a combustible, leak resistant, rigid
creation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items
attached to the creation container prior to creation. 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 he
removed prior to creation and placed in a combustible creation containez 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 chamfer. 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 die ose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO-NOT 1, �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
"I7e�Cripfion of Implanted"I'evice 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 he 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 creation chamber,
during the creation process and reposition the remains of the Deceased in order to facilitate a complete and thorough creation.
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 be 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 created remains of the Deceased and disposed of by the Crematory.
5. I/Wnol to,authorize
hinges,latches,nails,Crematory to separate and precious metals,and to dispose of e from the cremation chamber a anoncombustible materials, including, but
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 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 designed 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