McGilpin, Marilyn rrO gN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (1' c"� � ," � �
Name VIJ�r�Case #t
Date of Crematicn
Time Cremation Started � lU vl
Time Cremation Completed 1t
Type of Container
Remarks :
in S ! � .gA4
« II t+ \ I ?� A4'a
.A.Af
2�
TOWN OF UUEEN58URY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 774544776or if no answer
Cemetery
AUTHORIZATION TO CREMATE
in
The rd nce withrequests
sub,ject authorizes
Rules View
and Regulations to
accordance ,
cremate the remains of l /'/ �
All , z ����,� r ,l
(Nam
(Sam)
)
(
tCity) state) (Zip Code)
Street ,
who died on
day of 19
S (�
at --A) l ddre )
(Place)
Name and address of nearest 1iVing relatiVM or name of perturi
authorizing cremations//,: '36 VS
(Name) (Address)
Rela
tionship to the deceased I
Name of Funeral Home C, ,
IMPORTANT: knowled a the deceased has or
esent that to the best of botoydy. (Circle One)
has no pacemaker in his or her body.
^I certify that I have the full power and authorization to arrange
for the cremaion of
tion of the remains ersonal direct
possessionssPos
haveteither
the cremated remains, that any p protect, defend
been removed or may be destroyed, and agree to pclaims
and save harmless
lossPine
o any and al
r damagesewhich imay um fbemmade against thenby
and demands for
reason of or connected with the cremation of said remains as
ch claims or demands are or are not wholly
directed, whether s
gr undles r faI a or fr udulent. � �
,( D A d ,
i Hess (A res-
L
(Signature of Rel ve or egal Rep. an ass)
Signed on this date
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: .,
Cremation: -u r22 / A.)t U I r--t J �f� I PI
(Schieduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Prim N /e� (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by thi�irm by 144ce ent in a c lumbarium."
ff
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker or undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: L1/ r-A)� �.
(Actual Date) (Location of Crema
r
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
i
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.9J96
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned,cert. ,
t that q al right and authority to au*orize the cremation,processing and
disposition of the remains //� / (hereinafter referred to as the"Deceased").
ame o Dec
n Date of Dea Time of Death Z: 4AM. ❑PM.
I/We hereby request and authorize ll" (hereinaft {erred to as the"Funeral Home")to
Name of Funeral Home
take possession of and maize arrangements for the cremation of the remain,o the Deceased at / f
(hereinafter referred to as the"Crematory"). ame 4 Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we
understand that the services and of Fuuneral Home.ons e Crematory I/We hereby au�thbriz&e the Funeral ome toen the tarrangemains of the for the dispositionDd are o{the returne to
d
the possession and custody oy
remains of the Deceased as follows:
Is special handling required? ❑Yes IZI No Describe
Description of urn or container selected: 155 0 _Suitable for shipping: Yes ❑No
Deliver to � \ C Cemetery
N e an s 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*
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, 'processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
i. 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 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
maize disposition of any such noncombustible casket in any lawful manner it deems appropriate.
2. Mechanical or radioactive devices implanted 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 dispose of such items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT � CONTAIN 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 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 he totally and
itteversibly 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 i incl but not limited to, body prostheses, dentures, dental bridgework, dental fifgs, jewelry, and outer
1 a the remains of the Deceased, may be destroyed during the cremation process. I/We futt�ter
personal a`r_ any other than the cremated remains of the Deceased,are recovered from the crdmation chamber, they
authorize fro cremated retrains of the Deceased and disposed of by the Crematory.
be 6 so t, e Crematory to separate and remove from the cremation chamber all noncombustible materials, including,but
not lirmted to, , es,nails,jewelry and Precious metals,and to dispose of such materials.
6. P611owing 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 Deceased, any excess cremated
1 7 _ _1 r+ 1 TT .� •�� .� ___� __ 1
Ceased will me speCi{ic {�
jn the not]�P,4 ornQ Instructions in
to me/us
event a��ted m accordance with this Authorization h�oilaer 1,ue,In appropriate.
— crer
unclaimedf mail at t�s o{tl1e Deceased re any macular religious o e} °n, Processing and
dispose o{ oor ad o{120 eBa(es)indicated h nainunclairned for a c customs, disposition o.
12 the una cremated aft
the date such low Period o{30
Me agree to remated re a of that in th daYs, the Funer mde mains o{the written noti{i a Vent the me s
and j ,]_ , release�h� a Deceased in an cation . mailed a cremated re HO h�givr,
sition o{tlte c ty or causes
am rematedo{actin remato , manner it may d e�Funeral Horne i u°otlie Dece..
.teionsuc ce o{ Y nMmainst dthe Decea �au o ttorneys'{ aces, agents, eprnplo te. th axed and di-
the
13.ExCept as remains. eChanieal or radi hour,or myande �o{litiga{aon) Y and assigns, rnil
rFh in OUrQ "'co bon,
set o oachve devrces, or nre to co nhection with ess y
respeVe ate, this Authorization,no wa take Possession o{ o iden 'y the rump o{ D on and
14.I/�peeretand dents or emp panties, expressed Permanent Deceased
edge this docurxent °T rmplied arrangements {or, the
on abmd-be from
m' Ameraj H menot contain a cornpjete and 'tailed� made by the Funeral Home, Cremato
GNA , a copy o{the "Jj� jed de, nPtionti�every aspect°{ �'or any of their
r/weaIltCre n Fa the cremation rocess. j
ao t6t PERSONS)A cts' contairiin p /�Pe ntainecl in tj statementsHOjjjG�EMA AND g additional explanatory
r e have rec�ivedm ade he et.enre are�tr�uje�and CP�E d{lit DISPOSj ON
�-'`— -' (' tro FactB; I/we have read and understand the provisions
Zip Tel.No.
Addceae: ant e
tVA
W 11NL'ss'* s No.( bons 'p to De,
` ♦` • _ Date-
/ Name' Fun
WHITE:F C-PY YE�.iA :` PINK c—.e-r/C—toffy CVY