Harris, Margaret T07+N OF QUEEN 8`LlP.,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /rJ /i�Oli� / /r� Case #3
Dat e of Cremat i en �
Time Cremation Started
r
Time Cremation Completed Con
Type of Container
Remarks :
Ll'1 Ai N 94)/r'��R o� ld alo )
oZ .M
TOWN OF UUEEN98UPY
pINE VIEW CEMETERY
X
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (5191 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 ofs
-MaagaAd
(Name) SON)
I �/� �4 d i Z
(Street ) da(City)1 (State) (Zip Code) G
1
who died on 14 y of 19
at ( W UI� M 1 ,
tplace) (Address)
Name and address of nearest living relative or name of , person
a orizing cremations �aNVIJ&'
(Name) (Address)
Relationship to the deceased
Name of Funeral Homy
IMPORTANTs knowled a the deceased has or
I represent that to the berst of My 9 +
hear no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
the diion of
for the cremation of the rem
ains
the cremated remains, that any p ersonald todi possessions shaveteither
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
such claims or demands are or are not wholly
directed, whether
groundless false or fraudulent.
(Witness) (Addres,$)
tSignature of Rela ve or Legal Rep. and Address)
S gned on this dater 9
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.
�Vt" -
r
% r
"Customer's Designation of Intentions"
i
Name of Deceased.:
Cr4ination:
(Scheduled 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 ac6owled.ge receipt of a copy of
this form.
Signature)
(Printed Name) (Relationship to Deceased)
(Address)
i
) i
(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 columbarium."
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker f or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
��W rm Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINfEN Rev.4/96
�PG`;` -
AUTHORIZATION FO&CREM-ATION AND
DISPOSITION 03,Re,,.V.ZULILE��'HIS1S A LEGAL DOCUMENT.IT CONTA ItS--
CREMATION IS IRREVERSIBLE AND EMATION.
FI11iAL.lid DOCUMENT CAREFULLY BEFORE SIGIVG.
I(We,the undersigned,certify warrant and represent that Uwe have theme
Priority right under state law,to authorize the cremation, and �t and authority,an of no living rson who h superior
(hereinafter referred to as the"Deceased'), won fof the remains of '
Date of Death f F _ DAC
UWe hereby request and authorize1 _ I Time of Death r- r A.M. ❑P.M.
_ d" r
possession of and make dents for the cremation of the r to as "Funeral Home")to talcs
(herematter referred to as the"Crematory'l, remains the Deceased at
e erePerin rema 3
y aut o"r` e r a £
UWe understand thai the-services and
of the
P Cr��•y*4 be ftB�ed when the cremated
possession and custody of the Funeral Home.UWe hereby authorize the Funeral'home to arrange forth disposition remai ns ofthe d eceased are returned to the
Deceased as follows:
is of the cremated remains of the
shandling required? ❑Yes.)<No Describe
Description of uta or container selected;
❑ `to Suitable for shipping: ❑ Yes ❑No
❑ Release to family, a Cemetery
NUN
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship, u&Registered Man.
To:Name
❑ Other Addrm
-Y rPostal Service. " are cot responsible for aa+y loss or damage c remains
1 vaa Registered with the UnitedSWW-771
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance w'
all ruin taw the rues,regulations and policies of the Cremaltory and Funeral Home,and the a gerf rterm t
1• a remains o e eeease wi no a ac- a or ereit
rests and r' d lowing s and condition
cation ctainer.The CreiiGly is aathorized.to rove and spoSelof his ornaments and any.otr
nmacomhnhle items-gashed to the cremation container prior to cremation.In the event t
er
received by the he reW 16 of a casket or other container constructed of metal,fiberglass,or other noncombustible material,
I/weau#hize;lhe he remains of the Deceased are
of the Deceased to be rearoved.pnor to cremation and placed in a combustible cremation cmntainer.
T eihirher authorize the.Fun eraI Home or Crematory.to make disposition of any such noncombustible casket in any lawful
ma;�er it deems app riate.
rop
2• Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers,etc.)may create a h
when placed in the floc'chamber, The Crematory w not cremate any human remains which contain any t
��nted mechanic radlOacti device. In the event_flee not cre of the Deceased contain such y hazard
authorize the Funeral - Otte,its ages and employees,to remve ` Y type of
prior to cremation _ a device Uwe hereby
uc6 items at its discretii. t .mechanical devices from the remains ot:the Deceased
DECEASED DO ❑ DO ❑ ONTAIN ANY TYPE ti( �ED M CERTIFY THAT THE REMAINS OF THE
Please initial MECHANICAL OR RADIOACTIVE DEVICE: t
Listed below are '" lanted mechanical and radioactive
dogbaremains of the dispose of _ vvh�fich the Funeral Hsted: ome is authorized to remove from the a
pry'to cremation,and
Me30*1"of Implanted Device
DLptlen
Dean dbWaeted Device
,_. #111we
:.! Betio 1 _ _ - Miepoadffon
3. The cremation containerVO4fainin the remains of the Deceased be placed in the cremation chamber and will be totally and
irreversibly destroyed a ` exposure to intense heat and dir same.UVVe authorize the Crematory to open the cremat
chamber during the cremtition process and reposition the remains ds Deceased in order to facilitate a complete atpd t
cremation.
4. Certain items,including but not limited to body
arteles acco m b prostheses,dentures,dental bridgework:dental fillings,�'ewelry,and other personal
m►pan g t renains of the eceased,may be destroyed during the cremation process.UWe further authorize that if
Items,other t _to the**mated remains of the Deceased,are fecovered from the cremation chamber,they may be separated
the crenated remaiof the Deceased and disposed of by the Crematory.
rr-
S. 1JW ereby authorize the crematory t it separate and remove from the cremation chamber all noncombustible materials,including,
b limited to,hinget,,Iatches,nail,jewelry and precious metals,and to dispose of such materials.
6. cremation, cremated regains of the Deceased,consisting Primeugtai�rarily of bone fragments,will be mechanically pulverized
or other
ter an anidentiilable ctency per•to placement in an urn
7. Unless an urn or container suite for shi ment is purchased;the Crematory will place the cremated remains of the Deceased in a
container ._ is designatE aDyype of shipment.
S. In the ev urn or contai- 'is insufficient to accommodate all Of the cremated remains of the Deceased,any excess cremated
remains. - plied in a Wftdary container and returned to the Funeral Hump_tnapthav m;ta.sw..
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