Adelmann, Jane To q+N OF QUEEN.,5BUJ y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,ems /� p(,, �" Af
Name Z7/S�- &�zwlux Case # !ye
Date of Cremation !' ou ` oZ '�
Time Cremation Started 1.1113- 1'
Time Cremation Completed 17/64 19fm )
Type of Container lrJ D. L57 C19:5-. =,/F 7YoF-,, j7
Remarks :
;,79 Alm f
TOWN OF QUEENSUURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) Crematorium 745-4477 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 : 1 ,,
(Name) (Ser<) ,
��r q� G
(Street ) (City) S ate) (Zip Code) rI
who died on day of k
at N `',®/
(Place) (Address )::
Name and address of nearest living relative or name Pr person
authorizing, cremation :
(Name) (Ad,d ,es:-s.).t SPA,'" •
r �lw
Relationship to the deceasted .•. :.;�.
Name of Funeral Home
IMPORTANT:
sent that to the... bes.tir„of_,my kno4�lld`g,e, ,the deceased has or
as no pacemaker in his or,Th_er body. ,(C,i,rcla; bne)
I certify that I have the fu'11 power and` •aut:hori ka'i6%1 a arrange
for the cremation of the. remains a,pd to d.irect. lth,e .dispo ition of
the cremated remains, that any personal „ pos5e''ss-ionrs, hnay either
been removed or may be destroyed, and agree-'' to`„prot.,,._ 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.
( itness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date : ry
VN & DENNY FUNER-,:,a
Que�ssbv-ry, Ne\v Vp!,,., Im,
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
.K.a.i.a Date) (Location)
Manner of Dispootion.of Cremated Remains:
)'Burial at 0 Return to Family
0 Entombment at 17 El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge,receipt of a co
this form.
0`
L-4
(Signature)
1W
A�
A
Name) (Relationship to Deceased),
W
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days front
cremation may he disposed of by this firm by placement in a columbarium."
Printed N e of Funeral Director Signatme(ol Funeral Director D-
--crUndertalter orVndertaker
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:F..J H—Copy YELLOW:Family Copy PINK:Cr..ty Cc" CUSWMN R,-,.4/96
CNX.l
�oow4w AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
VW6,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no li 'ng,per on who has a superior
priority right under skate law,to authorize the cremation,processing and disposition of the remains of `
(hereinafter referred to as the"Deceased"). � f �/��
te of Death I �cJ Vv Time of Death W A.M. ❑ P.M.
I/We hereby request and authorize (ice �LZ
(((hhhere' after ref rred to as the "Funeral Home")to take
ner aum ner ome
possession of and make arrangements for the cremation of the remains eceased at
(hereinafter referred to as the"Crematory"), Name of Crematory
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home.
UWe 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.UWe 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 cpp4ainer selected: Suitable for shipping: Yes ElNo
V,
Deliver to u- Cemetery
me ana Aaaress ot cemetery
❑ Release to family
game or esignated Family Memberto Receive Cremated Remains
❑ 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/wB hereby
authorize the Funeral Ho nts and employees,to remove any such mechanical devices from the remains oithe Deceased
prior to cremation, and ispo o ch items at its discretion. I/WE HEREBY CERTIFY THAT THE,REMAINS OF THE
DECEASED DO C ON C NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOA_CTIVE.DEVICE.
Please' itia .
Listed below are all implan cal 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
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.UWe authorize the Crematory to open the cremation
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a e6mplete 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 authoLtze 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 acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is