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Belus, Raymond TOW OF CIUEENSBURY PINE VIEW CEMETERY 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: / ' (Na e) (Sex) i�U'7 Ab6t 121),C� y l�;r�S�3d2;1 (X1�(__ i�R a Ll - (Street ) (City) (State) i�cip �.vve. who died on t day of l�l f� I .C'. C 19 at -- (Place) (Address) Name and address of nearest living relative or name of , person authorizing cremations (Name) (Address) Relationship to the deceased � �f' Name of Funeral Home IMPORTANTs hat to the b the deceased has or I represent tast of my knowledge, 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 ther the cremated remains, that any personal possessions have defend agree to protect,been removed or may be destroyed, and P 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. (Witness) , (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 $50.00 . "Customer's Designation of Intentions" Name of Deceased: Cremation: (Scheduled Date) (Location) Manner of Disposition of Cremated.Remains: 0 Burial at ❑ Return to Family ❑ Entombment at ❑ Other (specify : I hereby designate the Disposition of Cremated.Remains and aAmowled$e receipt of a copy of flue form. (Signature) (Printed Name)y (Relationship to Deceased) R (Address) (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." Printed Name of Funeral Director Signature of Funeral Director 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 Dispoaition Signature Date +I9 WHTI'B:Funeral Hama Copy YELLOW Family Copy PINK:Crematory Copy CUSDMN Rev.4M ATTACH BOOKLET AUTHORIZATION FOR C *,�,� HERE D�1•it10N i\IOTI�• THIS IS A LEG, DOCUMEN , IT CONTAIN5 IMPORTANT p� DISPOs "�ON �r ` CREMATION IS IRREVERSIBLE �We,the n AND FINAL.READ THIS DOCUMENT C OVISIONS CONCERNING disposition o{the�remai, '�� d represent that I/ae have�e� FULLY BEFORF;SIGNINGE�TION. legal right and authority to authorize M` inafterthe cremation mg n Name Dec here' referred to as the `Deceased„d UWe hereby request and authorize Date of Death ). ;,'; f'. Time o{Death EJAX take possession of and Name o Fun %=:{iereina{ter referred to as the �pM.(hereinafter referred to as a�ngements for the cremation o e Home e "Funeral Home")to " f the remains o f th uWe autho '" C�a�e Crematory ). a Deceased at understand'" -" :{}1e rY to return the cremated remains of the Deceased to acne o Crematory the possess- ces a ob 'atiO�of the Crematory a possession and custodyof tj, y of the Fun Home. I/We hereb sh�be �when the cremated remains of e Funeral Home. I/we remains o foss: y authorize the Funeral Home to arrange{or thee dispositiondoare{the crematede Is spec' . re4uieed? Yes Q No Describe Description or Container selected: Q Deliver �,E� �; _ Suitable for slipping: ❑Yes ❑No t ❑ Release Name and Address Of t Cenieeiy Cemetery_ rY Cre ❑ S Batt Name o f Designated Family Member to Receive mated Remains IV Funeral Home or Funeral Home's agent ❑ SlUP via Mail To: N _ - ❑ Other Address: * etatsunjee andlW J Crema not resp for any loss or damage of exerte. ed remains shipped via Registered Mail with the United roeess' d'ipnob the remains of the Dec rized herein shall he Performed ed in accordance with all laws,the rues, an es of. tory and Fune Home,and the following terms and conditions: T6 remains of will W� cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation con Cre uthor d to remove and dispose o£handles, ornaments and Other ems aJjAed to - won. In the event the reno'no of the Deceased are received by the Crematory in.casket ts�u m , or other noncumbustible a4 I/,authorize the remains of the Deceased to be or other 'o a combustible cremation container:: 61her authorize the Funeral Home or Crematory to rem �� a casket in--any lawful manner it deeE s appmp late. C ant Ytlre remains of the D (such as pacemakers, etc.) may create a hazard 2 MedioaC a Crematory will not c nay human remains which contain any 1 type of iu the In the event the rem of the Deceased contain such a device, I/we hereby W� mechcm and employees, to remove any mechanical devices from the remains o f the Deceased ms retion. WE CERnFY THAT THE REMAINS OF THE DECEASED ' to ere CO OF R" ANTED CAL OR RADIOACTIVE DEVICE. ism�.. j the Funeral isadhonzed to remove from the remains of the Deceased Ply, ec 1> ante of as' �°"to I>�nuon x!: I sition ce r r" n of. Funeral Home. vi at v. o taaL ire ma is Ceased will_ " in Lion chamber and will be totally and cont ` re direct autho' Crematory to open the cremation chamber it go.y Palo the Deceased; io faeilitats a and thorough cremation. t►o denta j'. eWork dent-�ings. je�rY, ana other 3. , body prostheses, I/Os t , includ' not f ],e destroy�g the cremation process. ins o Decease used, reoovered from the nremation e�m� d7 artr4s acc n rem - ;Eb::%:o that if a ° an Dec of by the C mbushble materials inchv may be separated ore - the cemation nonco , to separate a materials. f5. I/We'hereby au the C s, by a�to dispose of . hone fragments,will be mechanically pulverized to not limited latches, ,000eieturg pia -- LL,. vmn _a1._...ntainer_ r 1 .