Wurster, John 7OUN OF QUEEM B �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &�Tzll L 12oE- NY
Name V��/Y 1� � (�J ��� Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed,)- ,(
Type of Container lLJn�2 Ze
c �4�J�d/i'.D
Remarks :
TOWN OF ❑UEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
-�oAli VyL)eS L'? j"rAJ.L —
(Name) (Sum)
(Street ) (City) (State) (Zip Code)
who died on a6 day of ocicJ615a 19
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
I.7.!J e 1' ! 1l\f 1i zs 1 5:2 it S• G r
(Name) (Address)
Relationship to the deceased VN( I1= _
Name of Funeral Home 2(_.�ar� + 17CNNY
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C.ircIe One)
I certify that I have the full power and -aut:horization 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 or damages which may be made against them by
reason of or connected with the crematAun of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
(Witness) (Address )
Signature of Relative or Legal Rep. and Address)
Signed on this date : cc, 1995
REC 4N & DENNY FUNEK.4 .if`2NIN ICE
53 Qudkv-Rrrtd
Qu itxavi bury,N oA--York 12 8
t,Yl£)792'. '114
Customer's Designation of Intentions"
Name of Deceased: o� t� Wu /Zs
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at X Return to Family
El Entombment at F-1 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signat►ure)
(Printed Name) (Relationship to Deceased)
t7!14,S
(Telephone Nu-6r)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may he disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signature,of Funer4birectr, Date"
or Undertaker or Under=�
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 Arson Making Disposition Signature Date
#9 WHrrE:Funeral Home Copy YELLOW Family Copy PM.Crematory Copy CUSINTEN Rev.4196
X7MA
AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
TION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
d, certify,warrant and represent that I/we Dave the full legal right and authority to luthoriie the cremation,processing and
poroeremains o +a ;•,i , 3 a��,yr i= (hereinafter referred to as the"Deceased'
Larne of Deceased )'
Date of Death f, f_ i Time of Death - RM. ❑p�
I/We hereby request and authorize .i"i r 'i � '`r '�`f
(hereinafter referred to as the"Funeral Home")to
Name of Funeral 14ome
take possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). Y Name of Crematory
I/We 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 eral Home.� I/We hereby authorizee Cremato $hall he�thlleFunhen the eral Home totarrangem for the Deceased are returned to
To
the possession and custodyodisposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes R No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
�( Release to family Iz L % -4 A(A =i�---js`, `P.?" �_-
Name of Designated Family Member 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, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,de rules,regulations and policies of the Crematory and Funeral Home, and the following terms and conditions:
1. The remains of the Deceased will not he 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 noncumbustible materials, 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
im lanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
autTorize 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 0 DO NOT [)C 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
-=- -D"enption 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 he 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, jewelry, and other
personal articles accompanying the remains of the Deceased, may he 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 hone fragments, will he 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 designed 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