Zurita, Libio oWN OF OUEEN5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �+� ( � �U� lfit-'7 Case # � (e
Date of Cremation
Time Cremation Started
Time Cremation Completed _1�
Type of Container i�j�SS tvo od orstr4 0 K-C
Remarks :
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TOWN OF ❑UEENSUURY
PINE VIEW CEMETERY
A
CREMATORIUM
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
cremate the remains of :
(Name) (Sex)
(Street ) (City) (State) (Zip Code)
who died on 3 rz_') day of -ni,L',6i'�126a 19 !
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
/Za WIVA ZO/3 4 an L )ytlkPJ..i j- J.C-"A�s r/+
(Name) (Address)
Relationship to the deceased �,e ( F� _
Name of Funeral Home_
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C-ircle 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 )
(SigniKure of Relative og Legal Rep. and Address)
Signed on this date : a&Z�i, �
53 Quaker Road
Qua*Lrisbu y.New Y(Kk
(518)742_l 1 14
"Customer's Deg*ation of Intentions"
Name of Deceased.:_ i ( C 3 10 1 t/t Z I 1 /A-
Cremation: ')t,cj. biz. 1`l`ili !�e,J L'It:rW `'/+, i yfzx
(S .doled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify :
I Hereby designate the DisposAon of Cremated.Remains and aclxnowledge receipt of a copy of
this form.
(S t
/'ZbS A,%i tit A .'c_l tZ I
(Print.d Name) (Relationship to Deceased.)
//
(Address)
(Telephone Num6r)
"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 Name of Funeral Director _T Signature of Funeral DW -�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 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Cramatory Copy CUSHMN Rev.4/96
XBOOKAUTHORIZATION FOR CREMATION AND DISPOSITION N
�
:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORT PROVISIONS CONCERNING CREMATION.
ATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
the full legal right and authority to authorize th rocessin and
ned, certify,warrant and resent that I/we have a cremation,p gpremains o +�./ J �L�lG!l N (hereinafter referred to as the"Deceased").
Name of Deceased
Date of Death /' Tune of Death F -;2G ❑A.M. XP.M.
I/We hereby request and authorize fl� E7e�A—(11 (hereinafter referred to as the "Funeral Home") to
Name of Funeral Home
take possession of and maize arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). 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 obligationsHome. / shall be
the es remains of the id are to
thepossessioand custody of the Fn al IWe hereby authorize the Funea Home to arrange for the the returned
remains of the Deceased as follows:
Is special handling required? ❑Yes ® No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
® Release to family 124S h hlr l(AS X.0 i2/
Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via U S Re istered 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.
and
remains of
he
in shall
ed in
The
lalws,,tEe rules, a regulations andn of of the Crematory and Funedral Home,eaand the followinbg terms and conditions: with all
g g g policies ry
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
maize 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 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. IIWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT F5C-J 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
4
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 fume. 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 be 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.
� 5limit d to,authorize
lunges,the
latches,nails,jewehy separate
and precious
metals,and to dispose of suc remove from the cremation h mer aterials.
noncombustible materials, including, but
not 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 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