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Kouba, George rl-O WN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Directors j Name �j�/��, Cg y Case # �Q Date of Cremation Z� Time Cremation Started Time Cremation Completed P 7 M i Type of Container Remarks : < A, J91 � P"M V"T �'�� TOWN OF WEEN4"U"Y �D pIW VIEW CEMETE"Y R ' CREMAtURIUM uualier Road, Uueensbury, New York 12804 phone (518) Crematorium 774-4477 476or if no answer Cemetery AUTHOR UnT IoN TO CREMATE The undersigyi�hrapdeSsubajedtautnaits#4Rples view and Regulations' in to accordance cremate the re sins oft rf Y& eU--r (cam) iN e) aV (City) ( tat@) ( Zip Codel (Street ) 2LO who died en d ay of lf� at (Address) (Place) Name and address of nearest liVing relatiVt or 0 -6MOM tlf'. pertori thoriYing cr mationt (Address) (NaMe) �c Relationstlip to the de eased ^� Noma of Funeral Nam VVV"` ;,,;;r,y� IMPURTANts knowledge, the dectrasad has or I represent that to the best of (Circle Unit' has no pacemaker in his or her body. Zr;r7 h to ge I certify that I have the eeren►ains full oand tower dd'irectr the td l�io`sibionnof for the cromation of that any personal possessions �i.�ve either the cremated remains, and agree to protoct, defend been reaaved or may be destroyed, g and save harmless Pine View Crematorium from any agils,p claims and deneanis for loss or damages which may be made ag89 reason of or ca►'"suchdclaims or with e dew►andsoare oorsaare�1notawholly directed, whether groundlessf false or fraudulent. t fitness) (Address) (signature of elative or Legal Rap- and Address) Signed or, 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 POLICIESt 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 {(olidays 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 persona]. 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, 5 . 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 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 for cremations done after 3 : 00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50 . 00 . ATTACH BOOKLET AUT HORIZATION FOR CREMATION AND DISPOSITION ON NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING Me,the undersigned,eerti{v, t and represen t I/we have the full legal right and authority o authorize the cremation,process and disposition of the remains o}{ (hereinafter referred o as the"Dec used' © t p (�lti ). Nameo D D to of DeathJlk @ 'I`une of Death ElA.M. ❑PM. I/Ve hereby request and authonzesk v'`�- tJ�. — (, \ (herein er referred tq as the"Funeral Home")to (_ Name of Funeral HVne i f take possession of and maize arrangements for the cremation of the remains of the Deceased a.t� 1 (hereinafter referred to as the-Crematory-). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased o the possession and custremains od of the Funeral Home. I/we and obligations of shall 6 fulfilled undrstand that the services f the Funeral Hmme.eI/Wee hereby authoriz6 the Funeral Home oen the ar arrange for the�disppositionn of theed are�crern�cremated to the possession n eustod .o remains of the Deceased as follows: Is special handling required? ❑Yes 1 I No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery Name and Address of Cemetery ❑ Release to family 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 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 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, fiherglass, or other noncombustible materials, I/we authorize the remains of the Deceased to he 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 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 0 DO NOT 0 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 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 he 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 to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, 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 he 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 hone fragments, will be mechanically pulverized to an unidentifiahle 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. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated __,1 a.,e I a,,41-T+"....e 1 TJ__ 4 4_o Lo ,44L A. nnn+ampr "Customer's Designation of Intentions" Name of Deceased.: .i�1- C Cremation x c.� = h', } �� ��1 �. V i f , (Scheduled Date) (Location) Manner of Disposition of Cremated. Remains: [I Burial at f Return to Family ❑ Entombment at ❑ Other (specify): 2 I hereby designate the Disposition of Cremated Remains and aclmowledge receipt of a copy of this form. (.¢nature) .f u)A 4 (Printed Name) (Relationship to Deceased) ( ress) 1 i (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 int a columbarium." Printed Na a of Funeral Director SienUltre of Funeral Director DSte or Undertaker U or Undertaker i f 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 Malting Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 n�