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Barnes, Joseph �O(WN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 t' Funeral Director-51 t d/T #2694y' Name T;5k�v7 , j �i/�,�� Case # A/�3 Date of Cremation` gA— -R� � f Time Cremation Started � AA^^ Time Cremation Completed I. IAAi Type of Container kltdop 90� Remarks : �. / TOWN OF UUEEN56URV PINE VIEW CEMETERY CREMRTORIUM Quaker Roadt Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 � AUTHORIzATION TO CREMATE The undersigned requests and authot^iztt Pine View Crematorium*�'ln accordance with and subject to its Rules and Regulato ,#.fro cremate the remains oft - J0 (Name) (SeK) 4(j) -4 (Street ) (City) (Ste e) (zip who died on day of at (Place) (Address) e. Name and address of nearest 1iVing relatisl� or, �nv.: o� a 11, outhorizin cremations - 70 . "+o r on C) (Name) (Address) Relationship to the deceased ` J ' JLs Rl ii"7,r. r iW 2�3QPc .._J Name of Funeral Home IMPUFiTANr s I nor I represent that to the best of My knowledge, t�irecira,s has no pacemaker in his or her body. (Circle One) certify that 1 have the full power and ,aut� orizatit- gf I c Y for the cremation of the remains ersonaldipossassions hAV4 1:7or the cremated remains, that any p d been removed or may be destroyed, and agree to protect, and save harmless Pine View Crematorium from any and all hems ms and demands for loss or damages which may be made against them oy reason of or connected with claims ore demendsoareoorsaare notains 89 wholly directed, whether such groundless# false or fraudulent. (Witness) (Addres-s) )Signature of Relative or Legal Rep. and Address) )(-Signed on this dater IZS � f 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 ersonal 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 whici 1pay be made against them by reason of or connected with the crema.:ion, of said remains and/or disposition of said remains as d'_rected, whether such claims or demands are, or are not wholly zndless, false or fraudulent . This authorization in addition to egular burial permit must accompany the remains . -Al_l remains must be encased in a casket or suitable alternate �ntainer. Caskets and containers must be of combustible material . styrafoam or plastic containers will be accepted. } The question relative to cardiac pacemakers must be answered on authorization La cremate form before the remains will be epted. Unless other arrangements are made the cremated remains will be T-Iiied via Registered U. S . Mail within three days of cremation to he funeral home handling the service. There will be a $20 . 00 charge for this service. e Cremation, Administration Costs and Recording Fee: Adult $195 . 00 ^hildren (age 13 months to 12 years ) $115 . 00 Infants (stillborn to (.2 months) $75 . 00 c ' Additional $50 . 00 charge for cremations done after 3 :00 P.M. tonday through Friday. Cremations done on Saturdays will be urged the additional $50. 00 . "Customer's Designation of Intentions" Name of Deceased.: �._'. :)• \ - ::a , Cremation: y-J (5 eduled Date) ' k' (Location) Manner of Disposition of Cremated Remains: ❑ Burial at Return to Family KI All ❑ Entombment at ❑ Other (specify): i t,'>tar t g j I hereby designate the Disposition of Cremated.Remains and,acknowledge receipt dw form. tu- (. 1 ) (Printed Name) 4� (� (Relations ' D (Telephone Number) "Cremated Remains which shall not have been claimed. within,f 12l�.` cremation may be,disposed of by this firm by placement in a cola Printed��arne of Funeral Director sign of Funeral Director v- or Undertaker Undertaker R "' 10 TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF Cremation: (Actual Date) (Locati ;' G.s Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) ,d Name of Person Making Disposition Signature PINK:Crematory Copy #9 WHITE:Funeral Home Copy YELIAW:Family Copy AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98 �h: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 k ow of�IjV' erson who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of(hereinafter referred to as the"Deceased"). ame o c Date 4 f eath LlyTime of Death ❑ P.M.,`7D A.M. I/We hereby request and authorize V� (hereinafter referred to as the "Funeral Home")to take Mum o omL�med possession of and make arrangements for the cre� ion of the remains of tt (hereinafter referred to as the"Crematory"). � Na ne of Crernatory 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 tt6t 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�f No Describe Description of urn or container selected: Suitable for shipping:m . ❑ Yes ❑ No ❑ Deliver to me an ress o me ry Cemetery I 'Release to family _ ame aml em to ece 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 Al governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: I rPmainc of th' Daccaled will not be accepted for cremation unless received by the Cremator ble, leak resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornament in a stand bus 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 farther 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 ' the cremation chamber. The Crematory will not cremate any human remains which contain any type of impla -mechanical or radio ive device. In the event the remains of the Deceased contain such a device I/we hereby an Funeral Home,.i and employees,to remove any such mechanical devices from the remains of the Deceased pra _'cremation,-and dis a of s items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO ❑ DO Off' ❑C TA N ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initi one. , C Nunnsted below are all implanted inical and radioactive devices which the Funeral Home is authorized to remove from the of the Deceased prior to cremation,and dispose of as indicated: cription of Implanted Device Disposition „iption of Implanted Device Disposition Yio 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 irreversibl 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. rr `� ' ain items,including but not limited to body prostheses,dentures,dental bridgework,dental e fillings welry,and other personal icles accompanying the remains of the�eceased,may be destroyed during the cremation process.I/ a further authorize that if any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber from the cremated remains of the Deceased and disposed of by the Crematory. ,they may be separated I I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,including, but not limtted to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. Folltg 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. '. 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. i. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,any excess cremated rt MaWS Will be plated in a secondary container and returned to the Funeral Home,together with the primary urn or container. k TIII)....do..��o..d.-A....4.......lod..o ♦6-1s.,..,,.._44t. 41._,._.,,_....... -0-__.._--"- ---- — . .. _ �.. .. ....