Colson, Susan i
TO`44N OF" QUEENSB`Zl_'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J" 1 ',-)6 /
Name '52LE'(9 Y cc Case
Date of Cremat i cn ,7 _ Lcl /
t
Time Cremation Started f yl 4r4 '
Time Cremation Completed 1" ye
Type of Container
Remarks :
Ailqbq
A17 �
TOWN OF OUEENSBURY
pINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 77-44776or If no answer
Cemetery 43-4
AUTHORIZATION TO CREMATE
in
The undersigned requests aautooi�gesRules view
and Regulations' to
accordance with and subject
cremate the remains oft
(SON)
i
(Name) j I
,2D �Jb)I 7
(Scree (City) S ate) (Zip Code)
19 qq
I
who d d on day of i
i
at
—ia-1-1(Place) (Address)
of nearest living relative or name of , person
Name and address
I
a t orizing cremat
(Name) (Address)
Relationship to the deceased
C�r - IYIc�hG. Q—
Name of Funeral Home I
IMPORTANTs
esent that to the best ofbodyknowledge,
the)deceased has or
herhas no pacemaker in his or
I certify that I lave the full power and authorization to arrange
and torect the diion Of
for the cremation of the remains ersonaldipossessionsshaveteither
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
demandsoareoorsaare notawholly ins as
directed, whether such claims or
groundless, false or fraudulent.
i
( itness) (Address)
�� QW
or Legal Rep. and Address)
(Signature of Relative 9 �
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 .
06
r
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: r 99c/ Al o'm
j (.Scheduled Date) (Location)
6
Manner of Disposition of Cremated Remains:
D Burial at eturn to Family
El Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a COW of
this form.
r .
(Signature)
(Printed Nam.) P/oc, I (Relationship to Deceased)
g(v
(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 columbariuln."
11 k L -0
• )1'4�y(Ll i Printed*.of Funeral Director of Funeral Director UAW4
/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 D-1-616D-)
(Location)
(Date)
Name of R-roon Making Disposition Signature, Date
#9 WHITE:Funeral Home Copy YELLOW Family Cow PINK:Crematory Copy CUSR-TrEN Rev.4/96
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION `
BOOKLET
ON]
HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMA I
-REMATION.IS IRi Rl VERSIBI,E,AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
-;. . `
ce ararran a`rid represent I/wee re right aid authority to autko #lie cremation,process(hereinafter »
I/We,the undersigned? rh� .- � ,�_.�., ( r referred to as the"Deceased).
disposition of the remains of _ �—
Name o Deceae /
Date of Death J ��� Time of Death ~' ❑Pam'
I/We hereby requesi-"Athorize L.t. t �EHome
c (hereinafter referred to as the rF eral Home")to
\!'Avg,
Na
1,
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")
d f the Funeral Home. I/we
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and Gusto 0
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains ofythe Deceased are returned to
t 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: Suitable for shipping: ❑Yes ❑No
Cemetery
;Jlpeliver to
Name and Address of Cemetery,
Release to family `
Name o Designated Family Member to Receive Cre fed Remains
❑ scattering at sea by Funeral Home or Funeral Home's agent
❑ ship via U.S.Re istered Mail*
To: Name:
Address:
❑ 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.
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 he 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 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 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, and dis ose of such items at its discretion. I/WE 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 aie imlanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,anMZ.
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 heat and direct flame. I/We authorize the Crematory to open the cremation chamber
during the cremation process and reposition the rarrtaim 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 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
a container which is not designed for any type of shipment.