Angel, Mary 'OWN OF QUEEVBUJZy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
y� n �Fuu,ne\ral DirectorL C& ` I- � ' J�1
Name �i'I�—� 1�, , ) M � Case # -'-���
Date of Cremation
Time Cremation Started y
Time Cremation Completed SN1
. 1
Type of Container
Remarks :
v ��� "7
TOWN UI= UUEENSUURY
13 I N= VIEW CEMETERY
CHEhIA'TUH I UI1
Quaker Road, Queensbury, New York 12004
Phone (510) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTI.10((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 of :
_MA 22Y A N 6&:--J. f L FY I+J. ;
(alai a (S a,►)
r--
56 rzoai CbWA6b IVY, !tea
(Street ) (City) (State) (Zip Code)
who died on '-f day of OG U13J=- 2000
at L nl s r-EAUS 14OS O[A L
(Place) (Address )
Name and address of nearest living relative or name`=''of person
authorizing cremation : "'ILV
HL IZ G'I lAth 6tltO
(Name) (Address)
Relationship to the deceased C� L�2 _—r �,.,.,.,
Name of Funeral Horne
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C•irc1e 0n.e)_ a
I certify that I have the full power and •aut:hori,za-t-i'on to arrange
for the cremati�un of the remains and to direct. the ispositivn of
the cremated Y1emains, that any personal possessions -hare 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) IT (Address )
r '
(Signature of Relative or Legal Rep. and Address)
Signed on this date : I
"Customer's Designation of Intentions
Name of Deceased: jV111cy - /i,2:J,EJ-1
Cremation: C L)
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
N Burial at turn to Family
Q-241J
El Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature) 7—
(printed Name) (Relationship to Deceased)
(Address)
(Telephone Numher)
"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."
4L
Printed Name of Funeral D rector Signature of Fun VqAirector 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
#9 WHITE:Funeral Home Copy YELLOW Family Copy PM:Crematory Copy CUSEMN Rev.4/96
eo
w� AUTHORIZATION FOR CREMATIO
N AND DISPOSITION 031Rev.4/98
N I(' ,: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,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the y remains of
(hereinafter referred to as the"Deceased"). a`meo a'`LaW f�i�1
Date of Death Q Time of Death ;�
I/We hereby request and authorize ,i'.r dw/ e1L �A.M. ❑ P.M.
me or�nner me (hereinafter referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory I). lPla Yi - inf
ame of Crema-10—ry-----�
I/We hereby 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 obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
Deceased as follows:
Is special handling required? ❑ Yes A No Describe
Description of urn or container selected:
19 _ Suitable for shipping: 04 Yes `No
Deliver to S i . M&Y2 iS �1 �nC1= h 1$ ( L ) V
ame an Bess o eme ry Cemetery
rz
❑ Release to family
ameo gnat amp y em r to❑ Scattering at sea by Funeral Home or Funeral Home's agent ecerve rema emams
ELI Ship via U.S.Registered Mail*
To:Name Address
❑ Other
*Funeral Home and Crematory are not r
Postal Service. esponsible for any loss or damage of cre mated remains shipped via Registered Mail with the United States
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:
1. The remains of the Deceased will not be accep
cremation container.The ted for cremation unless received by the Crematory in a combustible, leak
resistant,rip 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 noncombustible 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 make 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 t
e 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. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT X 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 be 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
cremation.
4. Certain items,including but not limited tobody prostheses,dentures,dental bridgework,dental fillings jewelry,and other personal
articles accompanying the remains of the eceased,may be 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 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 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 cremated
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.