McGrath, Lucia s
rl-nWN OF QUEEM
s5B UPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J./ � /U /i
Name h.UC! // McJ:W19ly Case
Date of Crematicn
Time Cremation Started Z tqd W
Time Cremation Completed
Type of Container c &191M
Remarks :
TOWN OF UUEEN98URY
pINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-44776or if no answer
Cemetery 45—
AUTHORIZATION TO CREMATE
in
The rdanceigwithranndeSts and subjectautooitse,Rules Vand Regulationsiew ' to
ing
accordance
cremate the remains oft
-em1
(Name) P(NA
CV
(Street ) (City State) (Zip Code)
who died on
day of 19
at L3'1` �
(place) (Address)
Name and address of nearest living relative or name of , person
authorizing cremations
OIL
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the deceased has or
sent that to the best of my knowledge,
tree iio �tcra!alcer it his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to ersonaldirect the Possessions disposition have either
the cremated remains, that any p protect, defend
been removed or may be destroyed, and agree to
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made againstthem by
in
reason of whethernsuch conected with e cremation o said
claims or demandsareorare notawholly
directed,
groundless, false or fraudulent.
mess) dress)
(Signature of Re'�a ive or Legal Rep. and Address)
Signed on this dates Mq
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 i requested,equested, 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 'Lou accepta:.ce of remains ?.s 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 yuestion relative, to cardlauc 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 $50 . 00 .
"Customer's Designation of Intentions"
Name Of Deceased:
Cremation-
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at ❑ Return to Family
❑ Entombment at +6ther (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form. �a
'($ignature)
(Printed Narne)I (Relationship to Deceased)
(Address)
11� 1
J
(Telephone Number)
"Cremated. Remains which shall not have been claimed, within 120 clays from the slate of
cremation may he disposed of by this firm by placement in a columbarium."
Printed Najne of Funeral Director Signature of Funeral Director Date
or Undertaker j or Undertaker
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
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSMEN Rev.Q96
C",4cv
AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98
�E:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CRE ATION-S IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY PAEFORE IGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,an know of no living-person rson ho has superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of CQ �
(hereinafter referred to as the"Deceased"). Q ame o er
of th �� 1 i r
Time of Death ❑ A.M. �pM,
I(We hereby request and authorize 1
ne
(herein r referredas the "Funeral Home")to take
Possession of and make arrangements for mation of the em .ins o the Deceased at
(hereinafter referred to as the"Crematory'). \ ame o rematory
UWe 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� No Describe
Description of urn or container selected: Suitable for shipping: �W Yes ❑No
❑ Deliver to ame Cemetery
an o em ry
❑ Release to family
Name of Desigmteel rarmlyMember 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,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 remaigs of�the QC ceased nil ng h cge�lg� �rema�j�y21 re�eivefl by the Crematory in a combustible, leak
resistant,rigs cremation container. 'he Crematory is aut orized 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 r ctive device. In the event the remains of the Deceased contain such a device I/we hereby
authorize the Funeral HomVoD
is and employees,to remove any such mechanical devices from the remains of the Deceased
prior to cremation,and dise o h items at its discretion. IJWE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO OT VC TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please init one.
Listed below are all implante al 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 "elry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I e 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. UWe 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.