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Briggs, Helen rl-O`WN OF QUEEN,5BUr�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, I EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name hlgz, ly ,��%�� Case # � Date of Cremation gioccD Time Cremation Started Ad 'ro7.9' IN P / t Time Cremation Completed so2-t l0 P) lr ' Type of Container 4)JO-9 o;L/VPrG/5*15F- O'lx=' / Remarks : l/�/� r4�r✓1 � i i i i i i i i i • Y y� 1, TOWN U1= UUEENSUUIIY 1A I NE VIEW CEMETE11Y C11EMI. YOUIUM Quaker Road, Queensbury, New York 12604 Phone (510) Crematorium 745-447'7 or iP no answer Cemetery 745-4476 f1U'I-1-I0111 u-IT 1 ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject t• o its Rules and Regulations to cremate the remains uf : - -r d �� F - <Namv) (self) (Street ) (City) //�� (St te) (Zip Cgde) who died on dZ � day of avc 2000 at (Place) (Address ) 1 : Name and address of nearest living relative or name, of, person authorizing cremation : (46 me) (Address) Relationship to the deceased L :F" _ "Irsw3O— Name of Funeral Home IMPORTANT: Lr e resent that to the best of my knowledge, the; ,dreef1 has or no acemaker in his or her body. (C.ircle, One); ,-,Y-,-s3sm I certify that I have the full power and •aut:hori;zatJ,,on tPearrange for the cremation of the remains and to dir.ect-:-t;h-er, dsirS.Poroddtion of the cremated v1emains, that any personal possessi,on:97,4-t. 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, alse or fraudulent. it e s (Address ) Z Ze (Sig u of Relative or Legal Rep. and ddr ss) Signed on this date : E 111,�4 N& 1)PENNY I-L"! i't"PY., "Customer's Des4mtion of Intentions" Name of Deceased: -Zle- Z" Cremation: (Scheduled Date) (Location) Mapn*i-of Disposition of Cremated Remains: -;9 Burial at L-, D Return to Family 11 Entombment at 11 Other (Spec*): i herehy designate the Disposition of Cremated Remains and acknowledge receipt of a copy of this form. y. (Signah—) k 3 (Printed Name) (Relationship to D...a) (Aare..) (Telephone Number) "Cremated Remains which shall not have been claimed, within 120 days from the date of cremation may be disposed of by this firm by plat e nt in a columbarium. (Printed Name of Funeral Director S' tore of Amoral Director Date or Undertaker or unJertaker 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 Porson Making Duposition. Signature Date #9 WHITE:Funeral Home C." YELLOW Aunfly Copy PINK:Crematory C." CUMTEN Rev.4/96 ., '.r— vJ .a.a,a..a,a..—J . a.a va w a.asuaua..a, —.— w ......a..,..v...b.ww,— —.. . .....o..o. ....,...w ..a..o, 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 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 &ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. 1 a Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the L 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 Fupecal-HqM"sL 3. The cremation container containing the remains of the Deceased will be placed in the crematioar-chaminalod will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematoy tt-oppen the cremation it chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a comlp) to and thorough C':u Fes:.CUk� Lt cremation. � ' y � j 4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillip s 4 w 2dW�otherpcir -inai articles accompanying the remains of the beceased,may be destroyed during the cremation process. le further authorize 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. OL USL 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 remagns-okhe 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. 9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is not possible to recover all particles of the cremated remains of the Deceased,and that some particles may inadvertently become commingled with particles of other cremated remains remaining in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby authorize the Crematory to dispose of any such residual particles in any lawful manner it deems appropriate. 10. Unless I/we ive specific written instructions in this Authorization,the cremation,processing and disposition of the remains of the Deceased will not be performed in accordance with any particular religious or ethnic customs. 11. In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days,the Funeral Home shall give written notice to me/us by certified mail at the address(es) indicated below. I/We agree that in the event the cremated remains of the Deceased remain unclaimed,for a period of 120 days after the date such written notification is mailed,the Funeral Home is authorized and directed to dispose of the unclaimed cremated remains of the Deceased in any lawful manner it may deem appropriate. 12. I/We agree to indemnify,release and hold the Crematory,Funeral Home,their affiliates,agents,employees and assigns,harmless from any and all loss,damages,liability or causes of action(including attorneys'fees and expenses of litigation)in connection with the cremation and disposition of the cremated remains of the Deceased,as authorized herein,or my/our failure to correctly identify the remains of the Deceased,disclose the presence of any implanted mechanical or radioactive devices, or take possession of,or make permanent arrangements for,the disposition of such remains. 13. Except as set forth in this Authorization,no warranties,expressed or implied,are made by the Funeral Home,Crematory,or any of their respective affiliates,agents,or employees. 14. I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process. I/We acknowledge receiving, from the Funeral Home, a copy of the booklet entitled "Cremation Facts" containing additional explanatory information about the cremation process. SIGNATURE OF PERSONS)AUTHORIZING CREMATION AND DISPOSITION I/We warrant that all representations and statements made herein are true and correct, and that Uwe have read and understand the provisions contained in this document,and that Uwe have received the booklet entitled"Cremation Facts". i Signature X $RI BA) k3li l56-5 Print Name Relationship to Deceased Address $ S )AL W i OD5 ,6 CT' oho Tel.No.(W�0) 6Fs3-D37s Street City State Zip SignatureA4 C61�4 4f1r Print Name `s ��� Relationship t Dec ased Address 1 / (/ Tel.No.(S/d) J Street City State Zip WITNESS ..�. fK 'v Date:OZA .,. ®?� ' Signature Print Name d Name and Address of Fu 94ral Home ©1998 SCI Management Corporation AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98 NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING REMATION. C 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 pe on who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of (hereinafter referred to as the"Deceased"). ame of Deceased Date of Death /p�2?�D p Time of Death 10A.M. X M. I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to take ame of Funera Home _- possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"). Name of Urematory 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 X No Describe Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No ❑ Deliver to Cemetery ame and Address of Cemetery ❑ Release to family Name of DesignatedFamily Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent E 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,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 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 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 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 ❑ DO NOT(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 to body prostheses,dentures,dental bridgework,dental fillings,�'ewelry,and other personal articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We further authorize that if 1 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. I 7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Decease-din a_l 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. 9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is - -- --- --- - -- -- -- --- ----- -- -- -- r-- . . .. .