Jenkins, Gloria TOUN OF QUEEM,5BUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directory,/rHH,C,
Name Case 0 ��7Q
Date of Cremation ✓
Time Cremation Started
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Time Cremation Completed l�, '7�7 <,I�rj r � n�-
Type of Container
Remarks:
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TOWN OF QUEENSBURY
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 oft
(Sex)
(Name)
(Street ) (City) (S ate) (Zip Code)
who died on
J day of l`�J_____
at (uv l
(Place) (Address)
Name and address of nearest living relative or name of , person
authorizing creme sons
(Name) (Address)
1i
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the deceased has or
I represent their to the best of lay knowledge,
as n 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, false or fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Rep. and. Address)
Signed on this datel—CL4�k�
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. ,klonday-Fridaxr= 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 .
4A
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"Customer's Designation of Intentions"?
Name of Deceased:
Cremation: j
ice-
(Schedulld Date) (Location)
.j
Manner of Dispos'ti f Cre d Remains:
1 0 o Burial at -7 U El Return to Family
F-i Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acitnowledge receipt of a copy of
this form.
(Printed N.)
4
(Telephone Ntu.1.)
"Cremated Remains which shall not have been claimed within 120 clays from the date of
cremation may he disposed of by this firm by placement in a columbarium."
klj
Printed Naxha of Funeral Director Sigma of F.".1 Director Date
or-tinJertaker \,)Dr Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: (Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (Manner Of Disposition)
if
(Date)
Signature Date
Name of Person Making Disposition
XAT,TAC
'YAC
OKLETAUTHORIZATION FOR CREMATION AND'IjISPOSITION
E•THIS IS A G DOCUMENT'. IT CONTAINS IMPORTANT PROVISIONS CONCATLt IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFOR GNINGTION.ned, ce`.i,L�',warra it and represent that I/we have the full legal right and authority to authorize the cremation,processing ansposon o te remains of ` -, (" ,: , ,, "j d
(hereinafter re"to as the"Deceased»
Name o Deceased )•
D to of Death_ Tone of Death hereby request and authorize (✓'. / ❑A M./(hereinafter ter referred to as the "Funeral Home")to
Name of E;eral 16me
take possession of and mare arrangements for the cremation of the remains of the Deceased at ll`'i j;
(hereinafter referred to as the"Crematory").
Name o Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession an custody o e
Funeral understand that the services and obligations of the-Crenia shall b �,when mated remains of the Dec axed 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: tabl f
Deliver to ; « 's t t 7,, rI„ Sur a or shipping: '` Yes ❑No
Na a and Address of Cemetery Cemetery
E1,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;
To: Name: Address.
❑ Other
Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Flail 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 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 metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container. Me 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 chamTer. 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, 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 wbich 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 hat and direct flame. Me 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 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 hone fragments, will be mechanically pulverized to
an unidentifiable consistency prior to placement in an urn or other container:
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