Green, Harry rro OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directors!Nd--),,G-� "
Name R E't'lA/ Case #
Date of Cremation !e — -Z.3 —
Time Cremation Started / /`/j /P/, Y\ I
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Time Cremation Completed
Type of Container ]' 2 195,4! �j ,�P�`(
Remarks : 7 /
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TUWN OF UUEEN5tlU"Y
PINE VIEW CEMETERY
1R
CREMAtURIUM
Uuaker Roadr Uueensburyr New York 12804
phone (518) Crematorium 745-4477 or iF no answer
Cemetery 745-4476
AUTHUR I ZAT I UN TU CREMt1TE
The undersigYid)iragdeSsubJedtautoo;tss,R ping
ules view
and Regulations/ in
to
accordance ,
cremate the remains oft
, 11 (SeH) �J�
IN(NameS� 7A
o /. (State) ( ip Code)
(Street ) (City) (S / Q ��,�,.�
who died on
l /T _day of L/G/C���- /\ G
at ,S
(Place) (Address)
Name and address of nearest IiVing relatiV# or mime of ptrlori
authorizing cremationt
(Name) (Address)
Relationship to the deceased
Lg��,-
Name of Funeral llome
IMPURTANts knowledge, the dtcvased has or
I repreSent that aeea+aker in hlis orit sherf body. (Circle (]ne). r,: .;,.;fj
has no p
that I have the full power and authorization to arrange
I certifyOri
for the rranration of the remains ersonOf
aldiplssession.'�sha,yeteither
the cremated remains, that any p roteck, defend
been remove or may be destroyed, and agree to p
all claims
and save harmless Pine View Crematorium from any and hem by
and demands for loss or damages which may be made •against.- ,
reason of or connected with the cremation of said' . :not .. owmsins as
directed, whether such claims or demands are or are not wholly
g u/ndlessi false or
frAkidul ent.
(Witness) (Address )
0 � �I
Le al Rep• and Address)
ttl
ure of Re lot ve or g
Signed on this date (
� C�� r
DISPOSITION OF CREMATED REMAINS
I hereby direct pixie View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify: F y CA )�
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 au'--hority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains , that any
personal. possessions have either been removed or may be destroyed
and agree to protect, defend and save harmless Pinb 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
cremat-ion . of sa W 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 m—t be encased in a casket or suitable alternate
container. Casket- 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 Regigte--ed U. S . Mail within three days of cremation to
the funeral hot;ie - :candling the service. There will be a $20 . 00
charge for this service.
Cremation, AdmiriisLration 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 .
d
A
- a
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(5ched d Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at - ❑ Other (specify):
r•
_ I hereby designate the Disposition of Cremated.Remains and,acimowledge receipt of a copy tsf'
this form.
(Si nature) Aj
(Print d ame (Relationship to Deceased. `Y
•
FAa
(Telephone Numher) 1
i.
"Cremated. Remains which shall not have been laimed within 120 .days f roo t�e�.,�ate of
c emation may be disposed. of by th' 'rm by pl me t4acbariutn:Printed Name of Funeral Director ignatureo neral Di �— Date
or undertaker or Undertaker
- J
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMA13�S
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 CU5INTEN Rev.4N6
ATTACH ,, AUTHORIZATION FOR CREMATION AND DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION 16 IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORF,rSIGNING
1/We,the undersigned,certify, t I/we right and authority to authorize the cremation,processing and
disposition of the remains O (hereinafter referred to as the°°Deceased°').
Name o
r
Date of Deal�Q "iR.�` `mie of Death + '' ❑AMPM
I/We hereby request and authorize (hereina r referred to as the"Funeral Home")to
Name Fun Home ,,,,
take possession of and make arrangements for the cremation of the remains of the Deceased at ,,,,,,�
(hereinafter referred to as the"Crematory"). Name 4 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 shall be fulfilled when the cremated remains ofythe 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 or co er cted: Suitable for shipping: lYes ❑No
Deliver to trite Cemetery
ame and 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: Narne:.._ ' Address:
❑ Other
' Funeral fTome and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United
States Postal Service.
The crjvwtio4e ein ball
and
tion of the remains of the Deceased authorized her s
governing laws,the rules, rocdspinreegulatz'onss anld policies of the Crematory and Funeral Home, d the followings termss and conditions:
ordance with all
1_ The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid
`erbmation container. The Crematory aauthorized to remove and dispose of handles, ornaments and any other noncombustible items .
attacce�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
mug umposirm 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
r6wTlaeed- the-ere�nation chamber. The Crematory will not cremate any human remains which contain any 'Pe 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
prkWtoe a1ia%anti-dispose of such items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL DFYIG .
riesse minal 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 he placed in the cremation chamber and will be totally and
irreversibly destroyed by prolonged exposure to intense heat and direct fume. 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 aecompanyin the remains of the Deceased, may be destroyed during the cremation process. I/We further
authorize that if any items, oer than the cremated remains of the Deceased, are recovered from the cremation chambe�y 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,jewehy 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 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
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