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Graham, John rID7+N OF QUEEN,5BUr y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, :NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Direct o r 0, Name �/� ��� fzw Case # �© Date of Cremation a,OQzn Time Cremation Started `j�,, 9,,X /7/M I Time Cremation Completed Type of Container Remarks : i d Zq i A ti TOWN UF= IJUEENSLJUI(Y PINT. VIEW CEIIETEUY CUEPIF17'0I(I UIh Quaker Road, Queensbury, New York 12804 Phone (510) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTI-10H I ZAT I ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains uf : C l GIZ (Name) (SP10 S <3- (Street ) (Ci y (State) (Zip Code) b�'who died on day of 2000 at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : (Name) (Address) Relationship to the deceased_ Name of Funeral Home C3l �- o IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (C.ircle One) I certify that I have the full power and •aut:horization to arrange for the cremation of the remains and to direct, the disposition of the cremated r1emains, 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 cremat:lan of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. fitness ) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date : _ � D i I h ) "Customer's Desioiation of Intentions Name of Deceased: Cremation: "A (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: 0 Burial at Return to Family 0 Entomhment,at 0 Other (specify): I hereby designate the Disposition of Cremated Remains and aChnolledge receipt of a copy of this form. (Printed N—.) (Relaiionship to Deceamed) "-so) A -j (Telephone Number) "Cremated Remains which shall not have been claimed within 120 days from the date of cremation may he disposed of by this firm by placement in a columharium." Printed N6e of Funeral Director Sqn4�v of Funeral Director Undertaker Date o r .17tid'ter -or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: of Disposition) (Location) (Date) X..o of p.,.Malting DAq--ti— Signature Date *9 WHITE:F...1 Home Cow YELLOW P.-ay copy PRM-Crematory C%)Y CUSMEN Rev.4/96 AUTHORIZATION FOR CREMATION AND DISP0.51TIAN ll'Rev.4/9 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,certify,warrant and represent that Uwe have the full legal right and authority,an�know of no iving verson who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of O n (hereinafter referred to as the"Deceased"). ,,rr....rr�� '1 ame o Date of Death W Time of Death El A.M. ❑ EN] I/We hereby request and authorize �^ (hereinafter referred to as the "Funeral Home")to tak ame o a er ome ` } possession of and make arrangements for the cremation of the re-dMtns of the Deceased at \V! (hereinafter referred to as the"Crematory"). Name o rematory JIM44wmby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Homl I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to th possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of th Deceased as follows: Is special handling required? ❑ Yes No Describe Descriptil m of urn or container selected: Suitable for shipping: Yes Nt ❑ Deliver to Cemetery amean o eme ry �' Rglease to family �1 u,l 1 — ame or besignateaember to Receive remat�Remams ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S.Registered Mail* Tw ame 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 eremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance witl all yoverniuglamw4ho-c-des,Cowl polieies-o€the.Crematory and Funeral Home,and the following terms and conditions 1. The remains of--the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, lea] resistant;rigid-cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and any othe noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased ar received by the Crematory in a casket or other container constructed of metal,fiberglass,or other noncombustible material 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 lawfu manner it deems appropriate. 2. Mechanical..or.radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazar when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type a implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we hereb, authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains oithe Decease prior to cremation, and dispose of such items at Its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF TH] DECEASED DO ❑ DO NOT ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICI '31•< . ll Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from th remains Ff the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition Descriptionol'ImplantedDevice - - - --- -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 be totally an irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the crematio chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thoroug cremation. 4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings.,jewelry,and other persons articles accompanying the remains of the eceased,may be destroyed during the cremation process.UWe further authorize that i any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be separate 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 pulverize 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 container which is not designated 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 cremate ..,:11 60..L...od;., n�onnn.inry nnntoinar Dori ratnrnail*n tha Frrnaral Anma tnaathar with tha nrimary nrn nr rnntainar