Markowitz, Mathew rl-O WN OF QUEENs5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /j ,C(E li r3, L7,E-1V1V
Name f/M 7�,�- 4) ftl ��� �,Z Case #
Date of Cremation
Time Cremation Started �/`/j
r
Time Cremation Completed
Type of Container Jwv 596X Z�Z-ad-,FoE
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Remarks :
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) 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 Regulatlons to
cremate the remains of :
I lei i LV,1` 1"1m3I,,,�5 vy Al E
(Name)
(Street ) (City) ate) (Zjp,Gode)
who died on a�1 day of �A(4,
(Place) (Address) ~ ",` ";b9
Cbri
Name and address of nearest living relative 'or `'ira "eyli�er-son
authorizing cremation :
(Name) (Address)
�1
Relationship to the deceased VV f---% 77
Name of Funeral Home J3LG�k
IMPORTANT:
I represent that to the best of my knowledge; 'th °�l'��'' sed• aas or
has no pacemaker in his or her body. (C.ircle (3►�e :'Y � 1''= yid
b
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to dire6t-.' t'he -d44Wsit .on of
the cremated remains, that any personal possession's 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.
i
(Witness ) (Address )
gnat a of Relate or egal Rep. and Address)
Signed on this date :
RUEGAN & DENNY FUN IJU-�%i, ,, i"4W'1C.-K
53 Quaker Roaii
1 a R4
"Customer's Designation of Intentions"
Name of Deceased: tfl i f ,I L, L
Cremation: 4 1
(Scheduled Date) (Location)
Manner of Dtspiasition of Cremated Remains:
0 Burial at �,Ji El Return to Family
11 Entombment at 0 Other (specify):
i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
4-
7-
L�,Vj
(Printed N..). (Relationslup to Deceased) '
A/
(Address)
14
(Telephone Number)
4.
"Cremates. Remains which shall not have been claimed within 120 days fro iP",i
cremation may be disposed of by this firm by placement in a columbboium.
Printed Name of Funeral Director Signature of Funeral
or Undertaker or Undertaker
TO BE COMPLETED FOUJDWWG CREMATION AND DISPOSITION OF CREMATED R1 I'*,
-WOO
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Date
Name of Person making Disposition Signature
#9 WHrl -Funamd Home Copy YELLOW.A-.IY C." PINK Crematory Copy CUSDMN Rev.4/96
}
oo�w�' � AUTHORIZATION FOR CREMATION AND DISPOSITION 03lRev.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.
t
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of living person who has a sup for
priority right under state law,to authorize the cremation,processing and disposition of the remains of j ffb is P1'1 {VZf<0 w l I
(hereinafter referred to as the"Deceased"). Nam`of
Deceased
Date of Death ;t5 00 Time of Death A A.M. ❑ P.M.
I/We hereby request and authorize 126aRl\( :2E j�L;!J!�!y (hereinafter referred to as the "Funeral Home")to take
[Nam of o imeral nome
possession of and make arrangements for the cremation of the remains of the Deceased 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.
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
X Deliver to L 1'`�(3 i.LL', 1 1 Cemetery
ame a�ofteme ery
❑ Release to family
Nam of Designatedamp em r to 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,ri,id 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 cremationi container.
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible e�asketin-asy lawful
manner it deems appropriate. 4
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers,etc.) may create a hazaliW
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any t6pe 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 ottthe DeiWased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THEr:
DECEASED DO C DO NOT X 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 th- ,
remains of the Deceased prior to cremation,and dispose of as indicated: -
Description of Implanted Device Disposition _0
Description of Implanted Device Disposition
If no instruction for disposition is given,such items may be disposed of at the discretioiff 6t the Elimerdl Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and'l.
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 fillin s ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.-Me further authorize that i;
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,.they may be separatcd.;_'l
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,' 1
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 mechanica_lly puly_sized
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 Deceaso-3 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 cremate=
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary Urri Or cinitainen
9. I/We understand and acknowledge best efforts,that even with the exercise of reasonable care and the use of the Crematory's b efforts,it is
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