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St. John, Joseph TOWN OF" QUEEM B 21P,.Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director / �� r �-/ r i Name ©� 1 /7 /� R/uI1/J�Case # Date of Crematicn �-2 ` 21? Time Cremation Started / Time Cremation Completed f��1 � � Ivl Type of Container Remarks : 11 11 "Zlz'J AnL Il 11 �`�n i9 Irv, 1 I i i i i i i i TOWN OF OUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-44776or if no answer Cemetery 45- 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 off (Na e) (Sex) (Street ) (C ty) (State) (Zip Code) who died on �2$ day of 19f at (Place) (A dress) I Name and address of nearest living relativt or name of , person authorizing cremations �,�.,•�� (Name) (Address) Relationship to the deceased Name of Funeral Home �� �- �.G� 1� " `F�� IMPORTANTs I represent that to the best of my knowledge, the dece=eda 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 ersonal direct possessions disposition either the cremated remains, that any p 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, whether such claims or demands are or are not wholly groundless, fa a or fraudulent. it (Wit ss) (Addres'le) i nature f Re ive or Legal Rep. and Address) t8 g Signed on this dates---- �� g DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as. 'o^lloows : 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. iti ALTT14ORIZATION FOR CREMATION AND DIPROVISIoSPONS SMON CONCERNING CREMATION. HIS I A LEGAL DOCUMENT. IT CONTAINS IMPORT ATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFUL�IiBEFC�RE SIGNING the full legal right and authority to authorize the cremation,processing and gned,certify,warrant and represent that I/we have a (hereinafter referred to as the Deceased"). 411 p remains o / Name o 13" f t. [IA.M. C4YP.M. Date of Death 'yb , , Tune o Death ,:T,� r (hereinafter referred to as the"Funeral Home")to We hereby request and authorize r Name a Home take possession of and make arrangements for the cremation of the remains of the Deceased at I -. Name o"Crematory (hereinafter referred to as the"Crematory") e possess' and custod of the Funeral Home. I we I/Weauthorize the Crematory to return the cremated remains of the Deceased to the p understand that the services and.obligations of the Crematory shall be fulfilled when the cremated remains ofythe 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 Suitable for shipping: ❑Yes ❑No Description of urn or container selected: Cemetery Deliver to Naine and Address of Cemetery/ ❑ 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 r*—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, e rules,regulations and policies of the Crematory and Funeral Home,and the following terms and onditions:c 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid any other,noncombustible items cremation container. The Crematory is authorized to remove and dispose i handles, ornaments the Crematory in a casket attached to the cremation container prior to cremation. In the event the remains of the Deceased by n' or other container constructed of metal, fiberglass, or other nOncumhusbble materials, Uwe 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 make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices im lanted 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, andgeC of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT ONTAIN 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 maw 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 crer n chamber and will be totally ad irreversibly destroyed by Prolonged exposure to intense beat and direct flame. I/We authorize the C tory to open the cremation c6m6 during the cremation process and reposition the remains of the Deceased in order to facilitate a d thorough cremation. 4. Certain items, including, but not limited to, bte prost6eees, dentures, dental bridgeaorh, ntal filjmg.,jewelry, another personal articles accompanying the remains of Deceased, may he destroyed during the 4femation pYoeess. IMe IEa:ther authorize that if any items, other than the cremated remains of the Deceased, are recovered from the exemauox, may be 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 - -- -'-----L:-L.. --4-A—;a. A f-,--Imo„f al,;,,,. f