Gadway, Bryan rro gIN OF QUEEN
-s5B U-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ✓ / !� � � ��
Name AI C.T' Case # �
Date of Cremation
Time Cremation Started O t4,0 j/IYI
Time Cremation CompletedZ'g'n f
Type of Container /► Dy!/I V is/ ' G/7:J � �//�y//
Remarks :
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TOW OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 775-44776or if no answer
Cemetery 45-
AUTHORIZATION TO CREMATE
in
The rd nceigwithrandests and subjectautooitses Pine Rules View and Regulations to
accordance
cremate the remains oft
�L
(N me)
(Sam)
(Street) (City) (State) (Zip Code)
day of /-k /�JZ(1 19�
who died on _
at
(Place) (Address)
Name and address of nearest living relative or name of , person
authorizing cremation:
ihl a f2 = J 2 imrz1
(Name) ( ddress)
Relationship to the deceased /VIa / �Lr�
Name of Funeral Home S r 1 � ! +✓��� I'�/ln�L �i4/l� � � ��-- i
IMPORTANT: knowled a the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
ion Of
for the cremation of the remains ersonaland to dipossessionsrect the shaveteither
the cremated remains, that any p defend
been removed or may be destroyed, and agree to protect,
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 ins as
°f whether or nsuchd with claims ore demandsoareoorsaare not remawholly
directed,
groundless, false or fraudulent.21
(Address)
tWitn ss) ._
I
(Signature of Rel or Legal Rep. and Address)
Signed on this dater Ap(zl
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 lose 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.
2VWe,
AUTHORIZATION FOR CREMATION AND DISPOSITION
TANT PROVISIONS
CREMATION T THIS IS A ON IS IRRELEGAL
ASLDO UM T. IT CONTAINS IMPOR D THIS DOCUMENT CAREFULLY BEFORE RSIGNING TION.
c ;warrant and represent that I,(we have the full legal right and authority to authorize the cremation,processing and
e undersigned, ert y {• : , .I ' (hereinafter referred to as the"Deceased').
disposition of the remains of t Nine ot Dec
eltsed
Date of Death :' t i`tTnne of Death ❑A.M. S.P.M.
,' (hereinafter referred to as the"Funeral Home )to
N
I/We hereby request and authorize ',� f'' '- �: ' ./
4 ' ame o Fun Home
take possession of and make arrangements for the cremation of the remains of the Deceased at
Name o Crematory
(hereinafter referred to as the"Crematory")•
f the Funeral Home. I/we
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod oto
understand that the services and obligations of the Crematory shall h fulfilled the Funeral to as arrange for the disposition dof the are ore et cremated
the possession and custody of the Funeral Home. I/We hereby auth
oriz
remains of the Deceased as follows:
Is special handling required? ❑Yes 5d No Describe
Suitable for shipping: El Yes El No
Description of urn or container selected: Cemetery
❑ Deliver to
Name and Address of Cemetery
S 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
Address:
To: Name:
❑ 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.
m accordance of the Deceased authorized herein shall be performed ' dance with
all
The cremation, rocessing and disposition of the rem
governing lawn,tEe rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
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 meta, fiberglass, or other noncumbustible 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
autorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains-e�-the Deceased-----�
prior to cremation, and dispose of such items at its discretion. I/WE HERBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT [K-] 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:
I
Description of Implanted Device Disposition
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 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
maybe separated from the cremated remains of the Deceased and dispos +l,
ed of by P Cron�at..cy.
ma-on c_ noncombustible mate ' ins ubut
5. I/We herebyauthorize the Crematory to se crateding,
not limitedto, , ewe an 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.
purchased, the Crematory will place the cremated remains of the Deceased in
7. Unless an urn or container suitable for shipment is
a container which is not designed for any type of shipment.
"Customer's Designation of Intentions"
Name of Deceased:
Cremation• �h
(►Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at 2L Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and acitnowledge receipt of a copy of
this form.
(Signature)
A SHA b ",66 1
(Printed Name) r (Relationship to Deceased)
(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."
Date
Printed Name of Funeral Director Signature of Funeral D�1�
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: (Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (1,1..r of Disposition)
(Location)
(Date)
Name of Person Making Disposition .Signature Date