Bullach, James TOWN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director���=t'��%�
Name /� % '� L 'C �.�._.f�<�TT Case # /
Date of Cremation
Time Cremation Started 1/r'J
` 9 I
Time Cremation Completed
Type of Container <;gi PP
Remarks :
I%Al) �'
GAN & DENNY FUNERAL SERVICE
53 Qualms Road
• Queembury,New York- 12804 - t •
(518)792-1114
"Customer's Designation of Intentions"
Name of Deceased: 1 A ly)cr S )3 L2 }�
Cremation:I J r
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at g Return to Family
❑ Entombment at ❑ Other (specify):
I Hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
-. c&N
(Printed.Na..) (Relationship to Deceased)
(Addren) .
(Telephone Number)
"Cremated. Remains which shall not have been Claimed, within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signature of Funeral DAqdior Date
or Undertaker or Un
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Dirpoerition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
i
#9 WHffE:Funeral Home Copy YELLOW:Family Cops PINK:Crematory Copy CUSINTEN Rev.9J96 �.-
XHERE
,
AUTHORIZATION FOR CREMATION AND DISPOSITION
F, THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANTPROVISIONS CONCERNING CREMATION.ATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNINGned, rwarrant .represent that T/we have the 0 le al t and authori to authorize isposition of the remains o{ •i L C t. `jam,e� G g authority the cremation,processing and
Name o Deceased
( (hereinafter referred to as the"Deceased").
Date of Death 16 f i i Tune of Death M®A . ❑PM.
I/We"hereby request and authorize /�:L (�i�1-! + L L; AI)/ (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
take possession of and make arrangements for the cremation of the remains of the Deceased at i t— 1/\/ C,.1c'
(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 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 ® No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
K Release to family t;/{r( /3t,)1,LQC,14
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
on
g and
position of the remains of
governing laws,'the rule,,nregulatidons and policies of the Crematory and Funeral Home,authorized
a herein the followinbg terms and conditions:
ormed in with all
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 noncomhustible 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
im lanted 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 = 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, 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 he 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 designed for any type of shipment.