Dier, John G. Sr. rrOq+N OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name jbLH C--.v Case #
Date of Cremation
Time Cremation Started
d
Time Cremation Completed ► � � i
Type of Container
Remarks : CzoL Doug
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TOWN OF UUEENSBURY
MINE VIEW CEMETERY
R
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORItRTION TO CREMATE
The undersigned requests and authohiz#t Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
c emate
the emains off
J
ae1e)
(Sam? _
(Street ) (City) (State) ( Zip Codel
who died on day o f 19=-i--
at CD
(Place) (Address)
Name and address of nearest 11Ving relatiVt or name of pertori
authorizing cremation f
(Name) (Address)
Relationship to the deceased
Name of Funeral Home:S�
IMPORTANT:
hat to the best of my knowledge, the deceased has or
,1__- _ resent t
Chas no acemaker in his or her body. !Circle One)
I certify that I have the full power and aut:horizatio^ 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 cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless# false or fraudulent.
(Witness) (Address)
(gignature of Rela ive or Legal Rep. and Address)
Signed on this datef ' L Z2� �19
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 her
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. t.c 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 . 09
* 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 .
tG'�wC
�oow AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98
THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of ��ZZ sst
(hereinafter referred to as the"Deceased"). th n p ame o ceas a
'2�aa l� �t,`7V
I/We hereby request and authorize to of ea Time of Death
— ❑ A.M. P.M.
ame o on (hereinafter referred to as the "Funeral Home")t0 take
possession of and make arrangements for the cremation of the remains o e Deceased at `
(hereinafter referred to as the"Crematory )". a 1,0 U kJ�l�/
. Name o rematory
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:
Is special handling required? ❑Yes�( No Describe
Description of urn or container selected:
Suitable for shipping: ❑ yes ❑ No
❑ Deliver to
ame an Release to family Tess o eme ry Cemetery
n �)-Q..Y`
ame 'gnat "amity em r to ett ve rema emams
❑ 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,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 agents and employees,to remove any such mechanical devices from the remains oithe Deceased
prior to cremation, and dispos h items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO El DO NO AIN A TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initi one.
Listed below are all implanted al and radioactive devices which the Funeral Home is authorized to remove from the
remains of the Deceased prior to crem ion,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 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�,�'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe 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.
9. I/We understand and acknowledoP_that PvPn with the PsrPrricP of rPacnnahln —A +h-.—-P tL 1L— _00—_
661
"Customer's Designation of Intentions"
Name of Deceased
Cremation:
(Scheduled.Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at 'Return to Family
i
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this dorm.
r
r-
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number).
"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 Signs'fure 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 WHITE:Funeral Home Copy YELIAW:Family Copy PINK:Crematory Copy CUSINTEN Rev.Q96