Joseph, Richard T- 0J+N of QUEEN B 9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '5 E -ty
Name LUt ✓ Case #
Date of Crematicn
Time Cremation Started �•3 0 T-1 �,
Time Cremation Comp/l�ete,d�Type of of Container
Remarks :
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TOWN OF UUEENSRURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Roadt Queensbury, New York 12804
Phone (518) Crematorium 775-447�6or 1F no answer
Cemetery 43-
AUTHORIZATION TO CREMATE
The undersigned raq�eSts and gubJectautooits#,Rules Pine Vand Regulationsiew ' to
in
accordance with
lcrmate the remains oft_ --
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(Street ) (City) ( tote) ip Code)
G ` 19
who died on day of
,11.1- �
at �
(place) (Address)
Name and address of nearest liVing relatiV# or name of porta"
authorizing cremation!
(Name) (Address)
(3 41- 7k
Relationship to the deceased
Name of Funeral Home
IMPORTANT: knowledge
the deceased has or
I esent that to the best of my 9 +
as no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
ion Of
for the cremation of the remains aersonald to dipossession% haverect the teither
the cremated remains, that any p t defend
been removed or may be destroyed, and agree to protec ,
claim S
and save harmless Pine View lseWhichimayum fbemmade a any nainstlthen by
and demands for loss or damages 9
reason of or connected with the cremation of said remains as
whether sh claims or demands are or are not wholly
uc
directed, agroydlrss#
false or fraudulent.(Wlt
11VHess) ddres-s)
(Signature of el ve or Le 1 Re d_ Ad r
Signed on this date t
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
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 bra
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 .
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V��44Q,
/031Rev.4/98
AUTHORIZATION FOR CREMATION AND DISPOSITION ATION.
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CO
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. pe
I/We,the undersigned,certify,warrant and represent that I/we have the full legal right and authority,a now o no 'v' g Wm who s
priority right under state law,to authorize the cremation,processing and disposition of the remains of ame o r
(hereinafter referred to as the"Deceased"). Time of Death lk A•M• ❑ PM'
Da Death
1 � ��y� /(�hereinaftJer referred o as o"Funeral Home" e
I/We hereby request and authorize /� mne o one �Sed at //�� v e7ag
possession of and make arrangements for the cremation of the remains o the Dec ame rematory
(hereinafter referred to as the"Crematory").
to the possession and custody of the Funeral Home.
I/We hereby authorize the Crematory li ations of the Crematory shall be fulfilled when the cremated remains of the deceased are return the cremated remains of the decea turned to the
I/We understand that the services and obligations
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains o the
Deceased as follows:
Is special handling required' ❑Yes X No Describe
Suitable for shipping: ❑ Yes ❑No
Description of urn or container selected: Cemetery
❑ Deliver to `ao em ry
Release to family a,ne ne amp em r to ererve rema emams
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via U.S.Registered Mail*
Address
To:Name
❑ Other
*Funeral Home and Crematory are not responsibl loss e for any 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 arr
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 lawfu,
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazarc
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type o
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we herebi
authorize the Funeral Home,its agents and employees,to remove any�such mechanical devices from the remains of the Deceaeei
prior to cremation, and dispose of such items at its discretion. VWE HEREBY CERTIFY THAT THE REMAINS OF THI
DECEASED DO ❑ DO NOT K 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 th,
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 ani
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the crematioi
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorougl
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings jewelry,and other persona
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/e further authorize that i
any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separate,
from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We herebl 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 pulverize4
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;
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 cremates
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
ze
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: r lZ,
(ScIl.a.lea Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at Return to Family
El Entombment at El-Other fspeci&.------
I hereby designate the Disposition of Cremated Remains and acknoledge receipt of a copy of
tbu form.
Oldnature)
P(A,
Pri—n ted Namel (Relationship to Deceased)
(Addr
R 1� KV
(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 co umbarium,"
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker 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 WHrM:Funeral Home Copy YELLOW.Family Copy PINK:Crematory Copy CUSH-rMN Rev.4/96