Hall, Barbara TO q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 5 i -w�-r
Name 14 Q-13 N-Q�L P A -, Case # b
Date of Cremation t — j Z,--
Time Cremation Started
Time Cremation Completed Ci �5
Type of Container
Remarks :
QD (� �
TOWN OF tlUEENStlURY
pINE VIEW CEMETERY
!b
CREMA MM UM
Quaker Road, Uueensbury, New York 12804
Phone (sle) Crematorium 775-44476or if no answer
Cemetery
AUTHUR I MMM TU CREMATE
in
The undersigned raq�eSsubajedtautooits0,Rules and Regulationsing ' to
accordance with
crema�t�e^ the remains f
U�1 � � (S e►2 1
(Naty)
' (Street ) (City ( ate) ( Zip Code)
day of
who died on
l l
at A _
(Place) (Address)
Name and address of nearest living relatiV# or name of ptrsnri
authorizing cremation!
tNaa�e) (Address)
Relationship to the deceased
Name of Funeral Home
ad
v.= `" I
IMPURTANTs knowledge, the deceased has or-
I r sent that to the best of my
has no pacemaker in his or her body. (Circle Une)
ll
I rpeiainsoand o direct the disposition
wer drtn
certify that 1 have the t of
er
for the cremation of ththat any personal possessions have defend
the cremated remains, o destroyed, g protect,
been removed or may and agree t View Crematorium from any and all claims
and save harmless Pine es which may be made against thew by
ins as
and demands for Ions or damag
i re
ed ith claims ore crem dearenodsoareoorsaare not
directed, whether such awholly
reason of or Connect
groundless# false or fraudulent.
e s) (Address)
(g;gnature of a ativ or Legal Rep, and Address)
�
U�'
Signed on this dater
D: SPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematoriu� : 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 auhority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains , that any
persona]. possessions gave eit-her 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 mace against them by reason of or connected with the
cremation . of of said remains and/or dispos tion 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 re.nain4 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 (stilljorn to
12 months) $75 . CO
* Additional $50 . 00 charge for cremations done after 3 : 00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the add-Atonal $50 . 00 .
A J
J
A
"Customer's Designation of Intentions"
Name of Deceased: �a
C)Cremation:
(scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
[I Burial at Return to Family
El Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a COPY�of,
this form.
Si 'a re)
(printed Name)- (Relationship to Deceased)
T U,
(A4jress) —J
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the elate of
cremation may he disposed of by this firm by placement in a columbarium.
\ � R�i {4�� �`tir.r�` `�� 4�.+ 1 � { `„ ��✓i�'6^T i IrCy f {� a/ � �`C�,,,.�
Printed N.1n.of Funeral Director Sign-94 of Funeral Director Dit,
or Undertaker U,Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation: .71
(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 PINK:Crematory Copy CUSINTEN Rev.4496
ATTACH e,000,
OOKLET AUTHORIZATION FOR CREMATTONAND DISPOSITION qD
}X111We,
EAE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
he undersigned,certy, d represent that lu a full legal right and authority to authorize the cremation processing and
disposition of the remains of Y' Cr (hereinafter refereed to as the"Deceased'.
Name of Deceased
I/We hereby request and authorize _� Dat of Deati _I`une of Death ❑A M. I PM.
" � `� ) ' (herein�{ter referred to as the"Funeral Home")to
Nammeo tape possession of and matte arrangements for the cremation of theHreomains of the Deceased at —1 Ak t<
(hereinafter referred to as the-Crematory-). Name of Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we
understand that the services and obligations of the Crematory ball be fulfilled when the cremated fyth 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 )'No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
ameren of Cemetery
X
Release to fmily ��''rt Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑Ship via U.S. Registered Mail*
To: Name: 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 cremation,�]�rocessing and disposition of the remains of the Deceased authorized herein shall he 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 accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid
cremation container. The 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 n m,urnb istible 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 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 H its agents and employees, to remove any such mechanical devices from the remains of the Deceased
prior to cremation, dispose such items at its discretion. IIWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO T. CO ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please ini 0 i
Listed below are all im 'cal and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,an�dispose of as indicated:
Description of Implanted Device Disposition
Description of implanted Device i° - Dirpoefti i
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 beat and direct dame. 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, jewelry, and other
personal articles accompanying the remains of the Deceased, may he 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,jewery and precious metals,and to dispose of such materials.
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone 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 designed for any type of shipment.
R_ Tr, +hp even+ +be urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated