Kane, Herbert TO'1 N OF QUEENs5BUP-.y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name I l - K ,� 1� Case # )
Date of Crematicn �
Ti me Cremat i on Start ed / t66 '4 f f
Time Cremation Completed Z'(X) f
Type of Container 130AV-.C) evasy<e0-
Remarks :
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TOWN OF UUEEN$BURY
PINE VIEW CEMETERY
CREMATORIUM
_ Quaker Road, Uueensburyt New York 12804
_�^ - Dhone (518) Crematorium 745-4477 or If no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
�he undersigned requests and authorize! Pine View Crematorium, in
00. sy err,.
`aCc'orClariqer with and subject to its Rules and Regulations o
% `ysb% 2vma't"e the remains ofe
yd al
(Name) (Sox)
tat@) (Zip Code)
(Scree � (City) 19
_. ., :who died on day of
at
(Place) ( ddress)
G rl.::.
Name and address of nearest living relatiVe or name of , person
authorizing creme ion:
(Nam ) (Address)
, l
Relationship to the deceased LLL
Name of Funeral Hom
IMPORTANT: the deceased has or
I represent that to the best of MY knOWCirele One)
has o pacema � in his or her body.
I certify that 1 have the full power and authorization to arrange
for the cremation
em of the remains ersonal direct
possession% have disposition
either
the cremated remains, that any D and a ree to protect, defend
been removed or may be destroyed, g
armless Pine View Crematorium from any and all claims
and save h
and demands for loss or damages which may be made against them by
ins 12,3
reason of wor hetconnected with claims ore demandsoareoorsaare notid awholly
directed,
groundless, false or fraudulent.
(Witness) (Add ess)
Z&V
( gnature of Relative or Legal Rep. and Address)
Signed on this dates
DISPOSITION OF CREMATED REMAINS
W
I hereby direct Pine View Crematorium to dispose of the ed
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 neafest
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
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 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.
UTHORIZATION FOR CREMATION AND DISPOSITI � 03,
O
IS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
I N IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
VWe, s warrant and represent that Uwe have the full legal right and authority,an4 k ow of no living person w o as a superior
priority< -to authorize the cremation,processing and disposition of the remains of _
/L
�
a eo
(here the"Deceased"). q
_ D to of Death I Time of Death f ❑'A.M. �EM-
I/We hereby request-md authorized —Ad (hereiqafter referrkd to as the "Funeral Home")to take
ameo ceral Home NV
possession of and make arrangements for the cremation of the remains of the Deceased at
matory
(hereinafter referred to as the"Crematory"). ameo re
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home.
VWe 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 kNo Describe
Description of upcn or container sel Suitable for shipping: )K Yes ❑No
Deliver to �1 Cemetery
ame ress o ry
❑ Release to family
ameo am em r to ece ve rema a ns
❑ 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 Hom ,its agents and employees,to remove any such mechanical devices from the remains of the Deceased
prior to cremation, and di ose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO 1 TT 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 fillin�s.Ljewelry,and other personal
articles accompanying the remains of the eceased,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 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.
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
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
F
"Customer's Designation of Intentions"
Name of Deceased.: i t —�
Cremation: ti r v ,t r `� 1' r ) _ 1_. ti ��J; . .� • , .
t (Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at )' ` `' ! _ ❑ Return to Family
❑ Entombment at ElOther (specify):
ire.
' 1 hereby designate the Disposition of Cremated.Remains and a8mowledge receipt of a copy of
this form.
1 (signature)
i - -
(Printed Name) (Relationship to Deceased)
(Atldrese)
(Telephone Number)
"Cremated. Remains which shall not have been Claimed. within 120 clays from the date of
cremation may be disposed, of by this firm by placement in a columbarium."
Printed Name 61 Funeral Director 'Signature of Funeral Director Date�
or Undertaker or Undertaker
DISPOSITION OF CREMATED REMAINSPO
TO BE COMPLETED FOLLOWING CREMATION AND DI S S
Cremation:
(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 CUSUMN Rev.4/96