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Simpson, James • wr.7Gt.at_.. ... _ .. TOWN OF QUEEN425BUP. S PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director,AF��1gA Name Case # �� Date of Crematicn L—R� ./ / J D ,Q I Time Cremation Started E / �� // Time Cremation Completed /X /T f m Type of Container �✓� / �' S�L� Remarks : i i it TOWN OF GUEENSBURY PINE VIEW CEMETERY a 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 remains of: (Name) (Seri) z 3rT a) ,ST D 0 65,AIS 13 U 2 11 Y �a�ls u (Street ) (City) (State) (Zip Code) who died on o�/ s day of el1)14L! 19_ at10e!•L (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: �RAvl a�°7 ate, nkY teb, (Name) (Address) Relationship to the deceased Jf�I� r r Name of Funeral Home /2��1�� l.� + IMPORTANT: I represent that to . the best of my knowledge, the deceased has or has no 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 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 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 grou� les , false or fraudulent. (Witn ss) (Address) (Signature of Relative or tegal Rep. and. Address) 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. S . 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 t 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 Monday through Friday. Cremations done sono Saturdays ne after 3 �will be charged the additional $50 . 00 . b w REGAN &DENNY FMRAL SERNICE, 43 QWM Road Queensbury,New Yod., 121804 (518)792-1114 "Customer's Desigmtion of Intentions" Name of Deceased: Cremation: (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: N Burial at El Return to Family Ei Entombment at 0 Other (spec*): I hereby desoiate the Disposition of Cremated Remains and acknowledo receipt of a copy of this form. (Signature) (Printed Name) (Relationship to Deceased) L 13 (Telephone Nu..]-,,) "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 for Date 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 Disposition) (Location) (Date) Name of Person Making Disposition Signature Date WHrM:Funeral Home Copy YIE110T FAWAY cow PINK:Crematory COW CUSE-IMN Rev.4/96 A�ytiS - - cP AUTHORIZATION"F( R - C -MATION AND DISFOSITIO..N E:THIS MLA LEGAL DOCUMENT.IT CONTAINS 03�R�.aro, r - CREMATION IS IRRERTANT PROVISIONS CONCERNING CREMATION. o FMAL•READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,warrant and represent that Uwe have ft priority right ender state law,to au t and authority,and kn w of no 6 ' thorize the cremation,procuring� _ Q ving person who has a superior (hereinafter referred to as the"Deceased'j. of the-remains of Date of Death La ! Time of Death Me hereby request and authorize r'1 6 Al f �L-'�hl�! �� � � � t� ❑ A.M. [ApM. possession of and make 8°� (hereinafter referred to as the "Ameral Homej to take (hereinafter referred to as the g'eCmrematorythe action of the remains of the Deceased at I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral I/We understand that the services and.objIgations return the Crematory shall be hrllBled when.the cremated possession and custody of the Funeral Home.l%We remains of the Home. Decew"as y _ follows: hereby authWize-the Fnnera!Home to arrange for the disposition of thesled.wins of the to the DbaII� 7 ❑Yes CA�No prsceibe Dmww an of urn or container selected: fiver to, A3 A I C S �,�1�[#; � Suitable for shipping. ❑ Yes ❑No © Rdeape to fancily Cemetery ❑ Scattering at sea by Funeral Home m..Funeral Hanws agent , ❑ Ship via U S.Registered Ma* 1b:Name ❑ i Address Q=!taiService. a—Wry are not respo. any±loess or via R .damage of cremated re the Cates tion,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with alI g© g laws,the rul. ations and O'HC -Of 'C o and Feral Home,and the a performed terms I. ='ii'lie.r _ l p h resista-remains �►'iIl net be.accepted.for cre aD g and conditions: �s - ` Winer.The Crematory is r� received by the Crematory in a combustible, leak . _ items a #e the cr and dispose of handles,ornaments and any other. y ttie Groins t10n container prior-tO eret"ation.In the event the remains of the Deceased are Uwe�tathorize the Tema�pf thee Deceased to be moved��ivr �of metal,fiberg►tass,or other noncombustible materials, I/We furl authors the Funeral Home or Cremator remotion and_placsd in a combustible cremation container. alb ri- y ition of any such noncombustible casket in any lawful 2. Mich r�ctive.' s implanted in the remains of the Deceased (such as pacemakers,etc.)may create a hazard wbea.�d fir. - -ehamber. The Cremator will need --_.`nbt`treinate any human remains which contain any type of liberal "t' etive device. In the eve ; rem of the Deceased contain such a device I/we hereby ' -agents and employees,to _ ch-mechanical devices from the remains prior and _. r _ ,of such items at its disc. - HEREBY CERTIFY THAT THE REI�I'S OF THE D69 NCONTAIN ANY TYi TED MECHANICAL OR RADIOACTIVE DEVICE. Please fikWene. Listed - nted ical and rad�ctive devices the Funeral Home is authorized to-remove from the remain$$f prior ti._,_ tion;and d pc►se of as ind'mated:. o�buan aimP�aa « 3. die c container container the remains of the Deceased' c d`lft fie creme.chamber and will be totall mod,"_ter it't'e�'ers troyed-by-p , a postfee to' .and Crematory too en the tlzamber the cremation- and reposition the-receasedder#o facilitate a completeg and tH cremation. = __ 4. Certain items, lud'. but not limited to. body prostheses,dens;*_9 ridgework,dental fillip ewelry,and other personal articles acco g e repains of the eased;maybe d:=`— the cremation procesnWefurther authorize that if an .items,of an>he c remains of the Deceased, from the cremation chamber,they may be separated the cre realains .thebecea and disposed of by; 5. I/We hereby a ize the C" ry#o separate.and remove ' critation chamber all noncombustible materials,including, b notnit hinges,l _ : aaTds,-jewl,precior Ito dispose of such materials. 6. Followingg cre ., ,the cremated remains of�Deieease = �primarily of bone fragments,will be mechanically pulverized to an nni'den . e consistency prior to plarneut an w` ether ti�ntainer. 7. Unless an urrt w contain _suitabfe-for shipment is urchast.d the Crematory will place the cremated remains of the Deceased in a container whici3t is not ated 1 r any type of shipment. _. B. In the event urn nor miner is kisuflicient to-aecommodiW' cremated remains of the Deceased,any excess cremated remains.wee placed-Ift:A-secoi y container and returned to' al Hnntp_tnQpthpr with th,,,,.:,..o...,..,...�,.