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Szmul, Antin rr-nWN OF QUEENs5BUJ�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, -,EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Rk--&O- Name /HW'& S�L M Case # rD Date of Cremation 11-2 —_ 2 y© d Time Cremation Started cr o Time Cremation Completed Type of Container Remarks : �. TUWN UI= l7UEENSBU14Y I3 I NE VIEW CEMETERY CREMATOR I UM Quaker goad, Queensbury, New York 12604 Phone (510) Crematorium 745-447.7 or if no answer Cemetery 745-4476 AUTI•IOR 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 remaiiis of : -- \AC�6, aid 1:3b . Sc)v C'15<k(S / 2', �IR (Street ) (City) (State) (Zip Code) who died on (o IFS day ofr Oe icd2z/ , 2000 at j - RAC-1 Sa>\( I� CSo r tk l�j.i «�.� %fk � /�` • (Place) (Address ) Name and address of nearest living relative or name of person authorizing cremation : I'Angi icy G P1 U� Ptc' &a Q) (Name) (Address) Relationship to the deceased IVVIl'G _ .,dJti Name of Funeral Home l2L:Gh L a 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 Y1emains, 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 . JA"J 7 Witness ) (Address ) (Signature v elative or Legal Rep. and Address) Signed on this date : /o�& za6w REGAN&DENNY FUNERAL,SERVICE 3 a 53 Quaker Road Queensbury,New York 12804 (518)792-1114 "Customer's Designation of Intentions" Name of Deceased: Au.l d S 1-IN I L Cremation: /Q 42o00 646-IAlGi1/ (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: ❑ Burial at X Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and acluiowledge receipt of a copy of this form. (Signature) (Printed Name) (Relationship to Deceased) (Address) Sozsll-k .,LEofS -1+ W (relep one 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." T&U1 1vo /d Printed Name—oT Funeral Director Signature of Funeral Dire ate 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 Dispos ition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINI'EN Rev.4/96 AUTHORIZATION FOR CREMATION N TICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT AND DISPO,SI.TIQ1 ; CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CA 031Rev.a OVISIONS CONCE I/'e,the undersigned,certify,warrant and represent that Uwe have the f R.EFUL"'BE- I- priority right under state law,to authorize the cremation full legal right and authority,and know of n livi V (hereinafter referred to as the"Deceased") g Processing and disposition of the remains of . � S� � a superior / ni+ Date of Death a.ie° er I/We hereby request and authorize \ Time of Death `�' EJ-IVUner AI /0 M. P.M Possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to the "Funeral Home")to tak (hereinafter referred to as the°°Crematory"). I/We hereby authorize the Crematory to return the cremated remains of the deceased to the Possession amen rematory _-._ I/We understand that the services and obligations of the Crematory shala Home, l be fulfilled when the cremated re possession and custody of the Funeral Home. P sslon and custody-ef4he_F Deceased as follows: I/We hereby authorize the Funeral Home to arrange for the disposition of heains of the ecremated remains to the of he Is special handling required? ❑ Yes Ltd No Describe Description of urn or container selected: ❑ Deliver to Suitable for shi I' Pping: =f�j{ ❑No Release to family awe an ress o eme ry 1 ( Cemetery ame ❑ Scattering at sea by Funeral Home or Funeral Home's agent° na amp em r to ecerve remat emams ❑ Ship via U.S.Registered Mail* To:Name _ ❑ Other Address *Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shi Postal Service. pped via Registered Mail with the United fates The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performe ' all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the follow' I, The remains of the Deceased will not be accepted for cremation unless received by the Crematory in rms and con it with wing terms and conditions: resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and an other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the D stible, leak 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 cremationnntain r. I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in an lawful manner it deems appropriate. container. 2. Mechanical or radioactive devices im lanted 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 type 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 oithe 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 JK CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. LiNtep below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains oflthe Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposiyhn 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 irreversibI 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 to body prostheses,dentures,dental bridgework,dental fillings 'ewelry,and other personal articles accompanying t ie remains of the beceased,maybe destroyed during the cremation process. /V a 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.anv PxePcc era-mnto.i