VanScoy, Kimberly 2r0` +N OF QUEEN4,5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name {' jl��l ��= � p / �f _`��l r Case #
Date of Cremation
Time Cremation Started 6/,.
Time Cremation Completed
Type of Container /\--
Remarks :
,41 i41 N ,C3lJ/rit��R Oaf =yJ�: rI11
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K _ TOWN OF QUEENSUURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12604
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
crem .te the remains of :
yan'SmA
(Name) - (Sex )
�`� � Mp(Street ) (City ) (State) Code )
�� 19
who died on /3� day of C 19 _
at
(Place) (Address )
Na.m,e: antd , address of nearest living relative or name of person
a.uth;ori,zing .crema ion :
11
(Name>>4 yan
SC (Address )
Relationship to the )¢ eased
`Name 'of ' Funeral Home
t 'IMPORTANT:'
sent' that 'to the best of my knowledge, the deceased has or
as no acemaker in his or her body. (Circle One )
I cert`i'fy',that I ' have the full power and •aut:horization to arrange
'f'or' the7;•cremati'on of the remains and to direct the disposition of
the) cre'Mlart)e`d "`remains, that any personal possessions have either
been r. emo.ved or may be destroyed, , and , a,gree to protect , defend
and . s'ave:._har;,mless Pine View Crematorium from any and all claims
and s"-.demand"s'{r`for"r'loss' 'or damages' which may be made against them by
reason ' of. or connected with the cremat.•io.n of said remains as
directed, whether such claims or demands are or are not wholly
ground lests, .'fa1se' or 'fraudulent. `
(Witness ) (Address )
J
" '(Signature of R atiye or Legal Rep. and Address)
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
o
1 . ; The crematorium will be open For cremations 5 days• a weep
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 V ►'ew 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 -ind authority to arrange for the cremation of the
remains and to direct the disposition of the crenated 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 buri.al permit must
remains. accompany the
ti- All , remains must be encased in cont a caset or suitable alternate
container. Cas.lcets t<and containers must be of cumbustible
�naft-Fr al . No styra"foam or plastic, containers wi 11 be accepted.
:: a i ..
,�. 5 The +question , relative to cardiac pacemakers must b
on�" ed
thQ`'autho1,�,, ion to . cremate form before the remains awillrbe
' accept edI "�'.+.,. m ..
Yri . t' i'a:r Y.,
Unle•s's other arrangements are made th.e cremated remain
s will
be mailed -via Registered U. S. Mail within three days of on
iat
to the funeral home handling the service.char..gei—for.*,th i s s ery i ce. There will be a cremation
), 00
Cremation,' Administration Costs and Recording Fee : Adult s105. 00
Ch.i.l.dr.e.n,,.�„tage•.. 13 months to 12 'years ) s11,0. 00 Infants ( stillborn
to 12� month's")t'+'s`j0. 00
ATTACH AUTHORIZATION FOR CREMATION AND DISPQSITION
BOOKLET
HERE 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 represen tha0we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o}{ (hereinafter referred to as the"Deceased").
ame
Date Death -+ Irene of Death f 6' ' X A M. ❑PM
I/We hereby request and authorize _ \ (hereinafter referred to as the"Funeral Home")to
-Iqaine of Fu6eAtl Home l
tape possession of and make arrangements for the crematiQu of 19e remains of the Deceased at
(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 custod of the Funeral Hoe.
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 ANo Describe
Description of urn or container selected: Suitable for shipping: Yes ❑No
❑ Deliver to Cemetery
Name and Address of Ce etery 's
II&Aelease to family 7 l'
f ame of Desig ted 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 cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,Je rules,regulations nd policies of the Crematory and Funeral Home,and the following terms and conditions:
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 noncumbustible materials, I/we authorize the remains of the Deceased to he
removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to
maize 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 disp se 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
Desoagticm ofdmplanted 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 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 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.
nehmite�to,hinges,latches,nailelthorize the Cremato to sarate and r,jewelry and precious metals,andm the and to dispose of such materiremation chamber all als.
noncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone 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 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
__11 L__1_--� :— - --__—�_-----1_:_-__—�__L_W_�1_1L_�,--___i u_�_ 1_�_LL___ 11_ Ll__-______________ ___ ____i_•____
hc
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at Return to Family
El Entombment at 0 Other (specify):
i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
V
(Printed Name) (Relationship to Deceased)
`"(Address)
-4
(Telephone Number)
"Cremated Remains which shall not have been Claimed within 120 clays from the date of
cremation may be disposed of by this firm by placement in A columbarium,.
1 j )j V
Printed N+e A
of Funeral Director Signature 4fVuneral Director Date
.--ai Undertaker or thiltaker
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 Berson Making Disposition Signature Date
#9 WHffE:Funeral Home C." YELLOW Family Copy PINK Crematory Copy CUSMIEN Rev.4/96