Barber, Florence zo wN OF QUEENs5BUq�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ��iC: Case
Date of Cremation //' —,cw
Time Cremation Startedzj
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Time Cremation Completed /�/ y /V/M
Type of Container
Remarks:
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TOWN OF OUEENSBURY �I
PINE VIEW CEMETERY 770�
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 oft
C �}
(Name) (Sam)
(Street) q (City) i S ate) (Zip Code)
who died on I l day of 19
at fii i��Q
(Place) (Address)
Name and address of nearest living relative or name of , person
authorizing cre tions
mn
(Name) (Address)
Relationship to the deceased
Name of Funeral Hom
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
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
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 or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, hether such claims or demands are or are not wholly
g undless alse or fr ud lent.
-(Wit ss) (Address)
- r
VJZ
(Si nature of Relative or Legal Rep. and' Address)
Signed on this dates L� \
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 REGFULATIONS
1 . The crematorium will be open for cremations 5 days a week : 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.
5 . Unless other arrangements are made the cremated remains will be
inailed 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: r
kh
Cremation:
(Scheduled Date) (Location)
Manner of Dispo�Rition of Cremated RemainS;,,
Burial at 6 A le-')3 0 Return to Family
11 Entombment at 0 Other (Spec*):
I hereby designate the Di itign of "ted �a Lnowledge receipt of a copy of
dw form.
',;Orr,
'47
(Signature) G.
(Printed Name) (Relationship to D;::Z,"i)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this k-jrm by pl ment in 4aol arium.
4L
Printed i, Director Signature of-Fun'e'ral Director 0ate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(M-of Disposition)
i (La
#dkl)
(?ate)
Name of Peron Making Disposition Signature Date
#9 wHris Funeral Home Copy YELLOW Family Copy PM:Crematory Copy CUSDMN Rev.4/96
ATTACH
BOOKLET AUTHORIZATION FOR CREMATION REMATIONAND DISPOSITION
NCI: THIS IS A LEGAL DOCUMENT• IT CONTAINS IMPORTANT PROVISIONS CONC
" CREMATIOW,IS LNREVERSIBLE AND FINAI,CONTAINS
R AD THIS DOCUMENT C
III CREMATION.s �We,the undexsign�� Certify AREFULLY BEFORE SIGNING
disposition of the remains of 1 t represent that I/we have the full legal right and authority to authorize the cremation,, . d
. :, t. processing an
Name o Deceas (hereinafter,referred to a,the"D
Date of Death , { eceased")'
I/We hereby request and authorize. t .rune of Death t
Elp
tape possession of and M.
Name o Fun (hereinafter referred to as the "Funeral Home")to
(hereinafter referred to as the Crematorygements{)r the cremation of theHreome
marina of the Deceased at Jr .
I/We authorize the Crematory to return the cremated understand that the services and obligations o{the Cremato shall be Name o Crematory
remains of the Deceased to the possession and custod of the Funeral the possession and custody of the Funeral Home. I/We hereby authoriz the Fun
Hocrematedme to arrange y Home. I/we
remains of the Deceased as follow,: mains the
di Deceased are returned to
for the disposition of the cremated
Ire special handling required? ❑Yes �7.-No Describe
Description of urn or container selected:
Deliver to,,"'
Suitable for shipping: �]Yes ❑No
❑ Release to family Name and Address of Cemetery Cemetery
❑ Scattering at sea by Funeral Home or Funeral Home's agentt� y Meml'er to Receive Cremated Remains
❑ Ship via U.S. Re i tered Mail*
To: Name:
❑ Other Address:
Funeral Home and Crematory are not responsible for any loss or damage of cremated remains stir red
States Postal Service. pp via Registered Mail with the United
.. The cremation ,Proeeeaing and disposition of the remains of the Deceased authorized h
governing laws,�the rules,regulations and olicies o e erein shall be erformed P f th Crematory and Funeral Homy,and the following terms and c nditions arice with all
1. The remains of the Deceased will not be acceped for cremation unless received
cremation container. The Crematoryby the Crematory in a eomhust�je j resistant
is authorized to remove and dispose of handles, ornaments and any other noncombustible'itemsd
attached to the cremation container prior to cremation. In the event there
e other container constructed of metal, fiberglass, or other noncumbustibl remains of s,Deceased are received by the Crematory in a casket
removed prior to cremation and placed in a combustible cremation container I/we authorize the remains of the Deceased to be
make disposition of any such noncombustible casket in anylawful I/We further authoriie the Funeral Home or Crematory to
2. Mechanical radioactive devices im lanted in the remains'of tthetDeceased Ouch as pacemakers, etc.) may create or ra p pp priate•
When placed in the cremation chamber. The Crematory will not cremate an
im lanted mechanical Y e a hazard
p or radioactive device. In the event theY human remains which contain any type of
authorize the Funeral Home, its agents and employees, to remove any such mechannical d Deceased contain such a device, I/we hereby
prior to cremation, and dispose such items at its discretion. I/WE HEREBY CERTIFY ekes from the remains of the Deceased
P of h •
DO = DO NOT }�'6ONTAIN ANY TYPE OF IMP THAT THE REMAINS OF THE DECEASED
Please initial one. �" IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is
Prior to cremation,and dispose of as indicated: authorized to remove from the remains of the Deceased
Description of Implanted Device
Disposition
Description o Implanted Device
If no instruction for disposition is given, such items maybe disposed of at the Disposition
3. The cremation container containing the remains of the Deceased will b discretion
placed on�{the Funeral Home.
irreversibly destroyed j�Y.Pro��ed exposure to intense heat and direct flame. e e authorize e Crematory
chamber and will be totally and
during the cremation prods and reposition the remains of theD order
t � the IY open the cremation chamber
4. Certain items, includin Deceased m ordler to facilitate a complete and thorough cremation.
g;-,lyut n6t limited to, body prostheses, dentures, dental bridgework dental fillipsjewelry,
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
may be separated from the cremated remains of the Deceased and disposed of by the
�C ematoryered from the cremation chamber, they
5. I/We hereb7 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
6. Following cremation, the cremated remains of the Deceased, consis materials.
an un0entifiable consisteri primarily Y of bone fragments, will be mechanically pulverized to
cl'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
I eoatainer-loch is not designed for any tvve of shitimer,+