Holcomb, Deborah . TOWN of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �'/�1
Name E p RbK, H4,0c)An. l:) Case # \
Date of Cremation
Time Cremation Started Nl,
Time Cremation Completed
Type of Container O' y),.�2 2a�
Remarks :
c OIL
'� A/
TOWN OF UUEEN48URY
PINE VIEW CEMETERY
R
CREMAfURIUM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 775-44476or 1F no answer
Cemetery
AUTNURItATIUN TU CREMATE
The undersigned requests and authorize! Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft
(SON)
(Nam )
(State) ( Zip Code)
(Street ) (City)
who died on
`a2n_� day of —Dcct ���cr - 19 99
Y.
at ) ; s
(Place) (Address)
Name and address of nearest living relatiVe or name of p�r!<ori
authorizing cremations
(Name) (Address)
Relationship to the deceased
Cd
Name of Funeral Nome ��'� c
IMPURTANTs knowled a the dec0sord hw• or
I represent that to the best of d (Circle Une)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for ion Of
the cremation of the remains and nalto dirossessionsect the s have teither
the cremated remains. that any perso p protect, defend
been cremated
a may be destroyed, and agree to
cimims
and save harmless Pine View vsewhichimayatorumfbeamade againstany and allthen by
nd demands for loss or damag
cremation
ins 89
ason of or connpctedclaims ore demands are oorsaare notid +
with th
wholl,y such ydirected, whether
groundless+ false or fraudulent.
a-+' (Rddress) r
(Witness)
(Signs re o �Rrl�ativyor Legal Rep. and Address)
Signed on this dater
DISP
OSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows !
Mail to
Other arrangements - please specify:
If pulveLization 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 kite 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
persona]. 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 .
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 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 .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.
N
"Customer's Designation of Intentions"
Name of Deceased.: 1. '
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at X❑ Return to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a cam,of
this form.
A
(Printed Name) (Relationship to Deceased)., Mf '
-
(Addmss)
7
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120E days.from tie slate of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker or Undertaker 't,
,: .,.
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains: '
(Manner of Disposition) s
(Location)
f
(Date)
Name of Person Making Disposition Signature Date
#t9 WME:Funeral Home Copy YELLOW.Family COW PINK:Crematory Copy CUSRVTEN Rev.4/96
G•� 'Off- f
AUTHORIZAVOR FOR=WMATION AND DISPOSITION
NOTICE:'1'IIIS IS A.LEG .IT CO2t'i`, TS IMPORTANT PROVISIONS CONCERNING CREMATION. '
CREMATION IS RSIBLE AND:FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
UWe,the undersigned,certify,war and represent thatl/we have the l l right and authority,and know of no living person who has a sup�,
priority right under state law,- ''"therize the eremotlon,processieg..aad diction of the remains of - c )o w rn
.me
or Beceasea
(hereinafter reftrred to as '�•
r Date of Death Time of Death ❑ A.M.
I/VWe hereby req authorize `�r�t s#� •s� " 7 c c� - IFu 11 c-Al M:orc (hereinafter referred to as the "Funeral Home'
possession o mare arrangements for the-cremation of the remains of the Deceased at r �i w iw�' r• r .r
(herein . "`- red to-as the"Crematory'). - ame gym.
.I hereby authorize the Crematory-to return the cremated remains of the deceased to the possession and custody of the Fun
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are
possession and,cudedy of the Funeral Home.I/we hereby authorize the Funeral Home to arrange for the disposition of the cremated ;+
Deceased as follows:
Is special handling required? ElYes X No Describe
Description of urn or container selected: Suitable for
❑ Deliver to NOWY
❑ Release to fanWy
❑ 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 dmwof cremated remains sWped via
Postal Service.
The cremation,processin and disposition oftkt re " "'+of a Deceased authorized,he�rein.shall b ormed in ac
all governing laws,the rules,regulations and policies of the Ci;61nattbry-OmMh,tililfUeme,,and th wing terms and
1. The remains of the Deceased will not be accepted for eration-unless rece' b_ tJie ry in a co st e, le
resistant,rigid cremation,contaiw.The iCr tory1 aiwthorized to re ;ornaments and any nth
noncombustible items attached to tIWW0mat, tamer .r' ev ins,cl£.th eased
received by OW'Crematory in a casket or'e�er container'" s r cted _ metal,ribei"_` , u Ater
I/we hathorize the remains of the Deceased to i n I o elre att `contain lqiaF vi
l
I/�We further authorize the Funeral Home or Crematorq'o make disposition of any su � t q any
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased(§utd rs � � ate,. haz@
when placed in the cremation chamber. The Crematory will not cremate matain 8n
implanted mechanical or radioactive device. In the event the-rem dli a device II�e- ere
authorize the Funeral Home,its agents anddeniployees,to remove any sy��mecbanic e`De. ..
prior to cremation, and dis of uch items at its di�retion. I//�wWEE ItEBN"e_
DECEASED DO ❑ " 'DO NOT . ONTAIN ANY TV- OF IMPLANTED
Please init' one. v
Listed below are all implanted mechanical and radioactive devices which the Funei t me-is authorized
eased
remains of the Dec prior to cremation,and dispose of as indicated:
Dmr"on d impwoced Device Diepoddon
._
Dan ip"of Implanted Devke
If no instruction for disposition is given,such items may be disposed of at the di
3. The,cremation container containing the remains of the Deceased-Will. ti
irreversiblyy destroyed by prolonged exposure to intense heatanddirect "e.I/We .
chamber during the cremation process and reposition the remainsef the Deceased
cremation. `
4. certain items,including,but not limited to body prosthe ,den dentitlbridge
articles accompan the remains of the bec >may be destrdyl durnig the
any items,o0or t o the cremated remains _ ecovered fr6m .
from the cremated remains of the Defieased and . of y the Crematory. s:
..� ,.
. ..
$: by authorize the Creamtory,�i: rate t frorn the cremation cha
b liited to,hinges,latches;naiH;jewelry and ..
r ef•b
- r of a container.-
n
'ne r sui
ent is urcbased a Crematory wig
n or tai tabhi
ur -
7 Unless.an ,
8. In the el , i co is insufficient-to a _. to of the.cremated
remains aeed-in a secondary . .and:fttiirtia #o a Funeral Home,
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