Grenno, George 2r0l+N OF QUEENs5BUP,
-Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name G 1-()�-Z& E 110 . K(ric ase it S35—
s
Date of Cremation l - I q 7
Time Cremation Started s-s n -\,-
Time Cremation Completed l ' 0 P ry
Type of Container
Remarks :
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All.
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
14
CREN(TroR I UM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-447*7 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
cr mate the re ains of :
e�Tr o ---
(Na
(Street ) (Ci ) (State) ( Zip Code) q
who died on D Mvday of - 199 1
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cr mation :
AMno
(Name) (Address)
� S Relationship to the deceased
1
eased w 1T
Name of Funeral Home Z��
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle 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 cremat.-io.n 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 : M
07
AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.08
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.REA-DTHItDOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the fii legal right and authoriZc
know of no li n who has a superior
priority right under state law,to authorize the cremation,processing and d_f the remains f�. (5 J
(hereinafter referred to as the"Deceased"). } Name" n , ,.- -.
,"`� Date of Death 11 `��, Time of Death 1 ' '-- ❑ A.M. KEM.
I/We hereby request and authorize �r' `� h i C--r-,n
referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the. the Deceased atJ
(hereluafter referred to as the"Crematory'). Name of Crematwy
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home.
UWe mtdwstand 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>3 No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Uetwl Cemetery
Release to family .j`� (_3 no - U�t=
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via u S. Mafl•
To:Name _
❑ Other
ome and Crematory are not responsible for any loss or damage of grated remains shipped via Registered Mail with the United tales
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 4gents and employees,to remove an such mechanical devices from the remains tithe Deceased
prior to.cremation,,and dispos such items at its discretion. I� HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ D E�VONTAIN 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:
Deaat�tloa�rmpLeeed De+tce DiepoelHon
Description of implanted Device Diepoeition
t at .
3. The cremation container containing the remains of the DeceasedwiB 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 c
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorooug
cremation.
4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillip s 'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process. 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. 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.
0 IIWP nndPratand and arknnw1PduP_that Pven with the eYercisp of reaconahle care and the use of the Crematorv's best efforts.it is
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"Customer's Designation of Intentions
Name of Deceased:
\J) ,
12 Cremation: N o ' ;
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
0 Burial at INVturn to Family
11 Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
the form.
ti
---------------
(Panted Name) (Relationship to Deceased)
U
(Telephone Number)
"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 Na6e of Funeral Director Signs'true of Funeral Director bate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (M&--of Disposition)
(Location)
(Date)
Name of F6roon Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW.Family Copy PINK-Crematory Copy CUSDITEN Rev.4096