Wieland, Aladar r7-O WN OF QUEE9\(4,5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,� l�
Name A419 J/(Al /V,D Case # ®
Date of Cremation le — 30 - cam
Time Cremation Started ,4/, "'. ,68 & MI
Time Cremation Completed lt56- M I
Type of Container My
Remarks : Zi�
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TOWN O (JUEENSUUI(Y
13I NC VIEW CEMETERY
CREMFI7'0I2 I UI4
Quaker Road, Uueensbury, New York 12604
Phone (510) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AU•I'I•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 remains uf :
(FVame) (bun)
(Street ) (City) �—(State) (Zip Code)
who died on �� day of 2000
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Ad ress)
Relationship to the deceased
Nane of Funeral Home ���,, , 7�.,, �� ,�.�I ►�•
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 cremati'vn of the remains and to direct. the disposition of
the crenated remains, 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 fraudulent.
(W i n e s ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date :
o 4w AUTHORIZATION FOR CREMATION AND DISPOSITION 03]Rev.4/98
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
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 person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
Gc C.r ,. p y?
(hereinafter referred to as the"Deceased"). Name or
Date of Death JO/;P'1)rA Time of Death ❑ A.M. ❑ P.M.
I/We hereby request and authorize ,.,� �.} ���,,,y, JC�S,,,s ,I� m (hereinafter referred to as the "Funeral Home")to take
"F a>�me—fo Funeral Home
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). ame o rematory
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 XNo Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Cemetery
ame an ress o cemetery
❑ Release to family
Name of vesiam"Family Member to Receive ciemaR 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,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 ofthe Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ElDO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial e.
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 totall,,-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 the-*)ugh
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings �'ewelry,and other perso l
articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further authorize tha,�lf
any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber;they may be separa
from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We herebl 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,any excess cremated
REGAN&BEN1Y FUNERAL SERVICE
. Qmwbury,Now Yett 12804 ,
(318)M-1114
"Customer's Designation of Intentions"
Name of Deceased: :x J,;
Cremation: % . ) W t ! -
- rT
(Scheduled Date) 4 (Location) `
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
ignature)
(Printed Name) (Relationship to Deceased)
l-
(Address)
(Telephone Number)
"Cremated Remains which shall not have been claimed. within 120 ways from the da' of
cremation may be disposed of by this firm by placement in a columbarium."
� � J �C 1 - '� �7 t �:�,J_�., .'� L�ra.r..r+!.� i'rJ s-✓•.�,_ .��,�.,
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker or Undertaker Jg.,
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 Disposition Signature Date
M9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96