Catlin, Dennis s
TOq+N OF QUEEM,5BU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
C !���
Funeral Director J`/le--
Name /Y Case it
Date of Cremation '!�' on�
—22
Time Cremation Started [ ,�/
Time Cremation Compl et edA7 fJ4— /T� ['M
Type of Container 4f-AfIO&I dM /5/r ::�/95'4:-
Remarks :
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TOWN OF GUEENSBURY
PI NE 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 remai s oft
(Name) (sex)
AS,+
(Street ) (City) 1(Sta e) (Zip Code)
who died on
1 day of 19
at
(Place) (Ad ress)
Name and address of nearest living relative or name of , person
authorizing cremations
(Name) (Address)
Relationship to the deceased
Name of Funeral Home lX1 TM
IMPORTANTs
I represent that to the best of my knowledge, the deceased has or
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 and to ersonaldirect the Possessionsshavetion Of
either
the cremated remains, that any p to rotect, defend
been removed or may be destroyed, and agree p
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.
Wi ness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this dater 5 i
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.
"Customer's Designation of Intentions"
Name of Deceased.: DEA!1V 1,S S k Q 17 10 A
t
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated;.Remains:
`Burial at I `d t ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I Hereby designate the Disposition f Cremated,Remains and aclxnowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the elate of j
cremation may be disposed of by this firm by placement in a columbarium."
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Printed Name of Funeral Director Signa of Funeral Director Date
ok Undertalter or Undertalter
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TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
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Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
i
(Manner of Disposition)
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(Location)
(Date)
Name of Person Making Disposition Signature Date
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#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINfEN Rev.4/96
a.acaaacauvu a.vuusaa— — V—LULy Lo auuaul"Vu w LCLLLUvc auu u"Fuoc ul alau ally vuacl —.-
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.
Mech
nical or
ctive
(such as
te
2 when placed laced in the acremationees ch mbler.ted in The Crematory
ns of the will not crremateda y humanaremainsswhich contain aana y tyhaea f
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, oi d—dispcge of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOTE='CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one t/1--t .1
Listed below are all impl nfbd,. areal and radioactive devices wbicb 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 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 he 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 he separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. In/We ot ab3'tauhingea,latches,nailer Crematory to
and parate an ious metals and to dispose of such d remove from the cremation chamber anoncombustible materials, including, but
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. • "
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the'Deceasea, any excess cremated
remains will he placed in a secondary• conMiner and returned to the Funeral Home,together with the primary urn or container
9. I/we understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is not possible to
recover all particles of the cremated remains of the Deceased, and that some particles may inadvertently become commingled with particles of
other cremated remains remaining in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby _
Cwmatny to dispose of any such residue in anytW malyae Trdmr*
10.Unless I/we give specific written instructions in this Authorization, the cremation, processing and disposition of the remains of the
Deceased will not be performed in accordance with any particular religious or ethnic customs.
11.In the event the cremated remains of the,Deceased remain unclaimed for a period of 30 days,the Funeral Home shall give written notice
to me/us by certified mail at the address(es) indicated below. I/We agree that in the event the cremated r8'mains of the Deceased remain
unclaimed for period of 120 days aftlenr the te such Deceased in any lawful mannen nobfi-cation is r tdma, the y deeFuneral
pp�priatee is authorized and directed to
dispose of the une ed crematedthe
12.I/We agree to indemnify, release and hold the Crematohauorized
Funeral Home, their affiliates, agents, employees and assigns, harmless from any
and all loss, damages, liability or causes of action (incluattorneys'fees and expenses of litigation) in connection with the cremation and
disposition of the cremated remains of the Deceased,as herein,or my/our failure to correctly identify the remains of the Deceased,
disclose the presence of any implanted mechanical or radioactive devices, or take possession of, or make permanent arrangements for, the
disposition of such remains.
13.Except as set forth in this Authorization,no warranties,expressed or implied, are made by the Funeral Home, Crematory or any of their
respective affiliates,agents or employees.
14.I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process. I/We
acknowledge receiving, from the Funeral Home, a copy of the booklet entitled "Cremation Facts" containing additional explanatory
information about the cremation process.
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSITION
I/We warrant that all representations and statements made herein are true and correct, and that I/we have read and understand the provisions
contained in cument,and the /weee received the booklet entitled"Cremationacts".
,Signature i /,•.. .4
Prit#t Nam-, � Relationship to Dec
Address _; t" C; }.r �( ? .d k. 1 . ; �"`• � 1 / , tF Tel.No.( )
Street City State l zip
Signature _ `;
' treet :
f Tel.NPrint Name )
Relationship, to Deceased
Address: 1. ` - — i � lfc
S r o.(
City St zip
WITNESS 11
Date: ,19
Signature t Name
rt i 3�
Name an ress of FuneralHorx{e
WHITE:Funeral Home Copy YELLOW:Family Copy PINK Cemetery/Zmatory Copy 031 Rev.10/94