Gallagher, Timothy TOWN OF QUEENBU.rky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
i
Name ��
Case #
Date of Cremat i onZ �ld 9
Time Cremation Started
Time Cremation Completed` /y
Type of Container ,/*� c2zf Z-A5—� /l
Remarks : -�
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SUN- y-yJ WU y: Ib AM 6 MLETON HEALY FUNERAL FAX K 5187933641 P. 2
pilt� yIEM C�s�ETERY
CREMQTUR IM
t]uaker Road, oulensburys Now York 1$904
phone (51A) Crematorium 145-4477 if me answer
s
cemetery
PAPMRI ZAT[ENi TU CRFM M
The undersigned requests and sutherislt pine view Crraatoriva, in
accordance with and subject to its Rules and Regulatie»s tv
zrtustyYlthe rvlirtns Off
TOIL
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"""`jaA4jn ' fate) (Zip Code)
I5tre•t) � tCity)
who died on
ay of 19
at tAddress)
(Place)
Name and address of nearest 11ling relAtlVe or name of p►rlen
authorising crem tions
" g(Name) tAddressf
Relationship to the deceased
Nage of Funeral Heae
IPpgTAMTI NY knewle ,d0e the deceased hot or
s h ker in his or her
rspacemasfbody. 1CircIv one)
I certify that I have the Pull power and outherisatiDn to arrange
for the cremation onoththataanys ersonaI and to d3pesseoolonsrvet the shaveteither
the cremated r*awl , protect, defend
been removed or may be destroyed, an agree o P
and save harmless Pine view esewhichlum mayfree
sad* against lthlmiby
and dtoands for loss or damages remains at
rem*on of or connected with the caseation of said
directed• or demands whether such claims ✓re or�!r*fne�R�pL� ,
proundls{! false or fraudulent. i°�J iPE�� R"'3'
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tAddrats)
tNitnrss) �ii(�
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481gn r of pee iv! or gall Re and Address)
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XHERENOTIC
AUTHORIZATION FOR CREMATION AND DISPOSITION
E THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
ATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
gned, certify,warrant and . resent that we ve th full al right and authority to authorize the cremation,processing and
disposition of the remains of t'"';- i `� V-, (hereinafter referred to as the"Deceased'.
Name o Deceased
D of th (Q' � `(`"l Tone of Death ❑AM. EJ P.M.
I/We hereby request and authorize, "v� "" (hereinpfter referred to as the"Funeral Home')to
Name of
eral
take possession of and make arrangements for the cremation of the reains of the Deceased at y i ` `•,/ i ....,k-'1J
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the created remains of the Deceased to the possession and custody of the Funeral Home. I/we
understand that the services
and obligations �ee shall b � when
ta the
Deceased
�m�to
the ossession and custody 0f the Fneral HomI/We bey rizthe Funeral Home to arrange for the disposition of the created
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: Suitable for shipping:-1�Yes ElNo
ElDeliver to Cemetery
JNa and
Address o emete
Release to family ':..f.l y ! �i„q( C.;i( "+tc � F.--; CA
Name of Designated Family Member to 11�ceive Cremated Remains
❑ Scattering at sea by Funeral Home&r 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 creation, 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:
1. The remains of the Deceased will not be accepted for creation 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 creation container prior to creation. 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 Me 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 tyype of
implanted mechanical radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
authorize the Funer ome, 'ts agents and employees, to remove any such mechanical devices from the remains_ of the'Deceased
prior to cremation, n dis of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NCB ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial One.
Listed below are all imp "yG"a•"cal 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
Disposition .,V..—•- — -"'--
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
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 creation.
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 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 unidentifiahle 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
"Customer's Designation of Intentions"
Name of Deceased: 1 All
Cremation:-, -I t V 4-
(scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at -)�IReturn to Family
El Entombment at El Other (specify):
I hereby designate theDisposition of Cremated Remains and rece
ipt ceipt of a copy of
this form.
(Signature)
(Printed Name) i (Relationship to Deceased)
(Address)
1761-r-
(relephone 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 columbarium.
Printed Nam of Funeral Director Sig*"of Funeral Director Date
0r4(jnA0t06r or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Date) (Location of Crematory)
Disposition of Cremated Remains:
(mt;;er Of Disposition) J
(l ocation)
(Date)
/I Date
Name of PIF son Making Disposition Srture
W-ffrW rhucra flumt copy YEUJOW.F-ndY COPY pum.C--t-,7 Copy CUSDUEN Rw-4/96
TOWN OF UUEEN38URY
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 authol^iztls Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains off '
&CJI,�'aJ-92a
rn (SON)
' (Name)
/�" , \
(Street ) (City) (State) (Zip Code)
who died on day of 19�
at
(Place) (Address)
Name and address of nearest living relatiVO or name of , person
authorizing cr761
tions
a
(Name) (Address)
Relationship to the deceased
Nase of Funeral Home
IPMRTANTs that to the best of my knowled a the deceased has or
j resent (Circle One)
as no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the ere�ation of the remains direct
possessions disposition
either
the cremated remains, that any personal rotect, defend
been removed or may be destroyed, and agree to p
and save harmless Pine View ewhich imay um fbe m m any and l
&do against them cl&i
and demands for loss or damages
reason of or
thernsuchdclaims or with e demands oare oorsaar remains
e not wholly
directed, w e
groundless, false or fraudulent.
(Wit ess) (Address)
(gi at a of Rel ive o Legal Rep. and Address)
q
geed on this dates
/
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
f
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.