Brown, Marion TOWN OF' QUEENs5BUP,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S/ MI
Name 14/ g1tolq ✓ tjl Case #
Date of Cremat i cn /0 �� l
Time Cremation Started yl
Time Cremation Completed A-L
Type of Container 6�-n�5 0_
Remarks :
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TOWN OF UUEEN98UPY
PINE VIEW CEMETERY
` IL
CREMArURIUM
Quaker Roads uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or If no answer
Cemetery 745-4476
AUTNURIZATIUN TU CREMATE
The rdanceeigwithrandeSsubjectautooitsesRules ine View and Regulations, in
to
accordance
cremate the re ns oft
ilf)c�l r — (sem)
(Name) G q
d —P 1
(City) state) ( Zip Code)
(5tr et ) �
19
who d d on day of
at
(place) (Address)
Name and address of nearest liVing relative or nag# of , perjori
authorizing cremations
(Name) (Address)
Relationship to the deceased
'
Name of Funeral Nome
IWURTANTI knowledge, the deceased has or
I represent that to the best of my (Circle Une1
has no pacemaker in his or her body.
I certify that I have the full power and authorizatioh to arrange
ion Of
for the cremation of the remains ersonaldi possessions rect the shave teither
the cremated remains, that any p and agree to protect, defend
been removed or may be destroyed, 9
and save harmless Pine View Crematorium from any and
all
t a by
and demands for Ives
claim
S
or damages which may be made against
ctr
with
reason of wh thernsuchdclaims or e cremation o said
demandsareorar remains
e not wholly
directed, e
groundless; false or fraudulent.
(Witness (Address)
`(Signature of Relative or cLegal Rep. and Address)
Signed on this date !
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 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 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 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 .
_ -a� 6KF71 967 M7
AUTHORIZATION FOR CREMATION AND DISPOSITION ` 4 031Rev.4/98
D� �E:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
UWe,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,an w of no living pe ho has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of rk/1 A
(hereinafter referred to as the"Deceased'j. 4
Date Death �� � Time of Death ❑ A.M. ❑P.M.
I/We hereby request and authorize ut"` r krred to as the "Funeral Home l to take
possession of and make arrangements for the cremation of the runs of-the Deceased at E'er reat-y
(hereinafter referred to as the"Crematory').
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:
Isspecialhandlingrequired? ❑Yes )� No _Describe
Description of urn or confer selected: Suitable for shipping: Yes ❑No
Deliver to L A ''' d`Y' a Cemetery
0
LJ' fotatt�ily
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via U S.Registered Mail*
1b:Name Address
❑ Other
*Rn�wal and Crematory are not responsible for any loss or damage R
:. -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
rewtant,riggid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and any other
nonEonthustible 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,
Vwe 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 wBi;ntot cremate any human remains which contain any type of
implanted mechanical or radioactive device. In the eveat.t�e,remains of the Deceased contain such a device Uwe hereby
authorize the Funeral Home,its agents and employees,to remi+n+e any such mechanical devices from the remains of the Deceased
prior to cremation, and dispose of such items at its discret[on. ]UWE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT ❑CONTAIN ANY TYPE IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all imelanted 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:
neaQipuo.orrmpl�eaa Device Dbpom-
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
irreversllA destroyed by prolonged exposure to intense beat and_direct flame.I/We authorize the Crematory to open the cremation
amber the cremation process and reposition the remains of the Deceased in order to facilitate a comp ete and thorough
4. Certain items,includbig,but not limited to body prostheses,dentures,dental bridgework,dental fillings,jewelry,and other personal
ardelm ontpan a remains of the beceased, b�e.des txoyed during the cremation process. a further authorize that if
any items,otlter AWthe cremated r_ ' of the are recovered from the cremation chamber,they may be separated
from the cremated remains of the Dew_ and disposed by.the Crematory.
5. I/We hereby authorize the Crematory to separate and renilovefrom the cremation chamber all noncombustible materials,including,
but not limited to,hinges,latches,nails,jewelry and Pi'edous metals,and to dispose of such materials.
6. Following cremation,the cremated remains of the Deceased, ting primarily of bone fragments,will be mechanically pulverized
to an unidentifiable consistency prior to placement in an dru or oltther container.
7 Fn Bhinl anf me v..erehavaul_tho rramatnry will nlarP the erPmutpA romskinq of the nP.rPnQPd in n
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
Burial at El Return to Family
El Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed,?4me) (Relationship to Deceased)
J
(releplion.Numl—)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed N ne Of Funeral Director Signat�ft of Funeral Director Date
or Under"" 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 YEUDW Family Copy PM:Crematory Copy CUSH-nEN Rev.V96