Kokosa, Ardelle rrO WN OF QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name gm, E � Case # f /
Date of Cremation
Time Cremation Started
Time Cremation Completed A l� f91/yt 1
Type of Container4y
Remarks :
TOWN OF ❑UEENSUURY
PINE VIEW CEMETERY
h
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) 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 F:
(Name) �\ (Sex) —
a
(Street ) (City) (S ate) (Zip Code) p J
who died on day of a;�
at �� UA-�
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremate n :
(Name) (Address)
Relationship to th�_... eased _
Name of Funeral Home )
.S> IMPORTANT:
I resent that to the best of my knowledge, the deceased has or
has pacemaker in his or her body. (C.ircle One)
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to direct the dis,position 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 cremat,-io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
(Witness) (Address )
(Signature of Rela ive or Legal Rep. and Address)
igned on this date :
0 E,'NNN F��'N I"k,
T!,
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: k. .
,(S4.duled Date) (Location)
Manner of Disposition of Cremated Remains:
0 Burial at ,Return to Family
11 Entombment at El Other (specify):
I hereby designate the Disposition Of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceaod)
(Add-so)
(Telephone Numl-r)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may he,ldisposed of by this firm by placement in a columbarium."
Printed N+of Funeral Director Signature of Funeral Director Date
or Undertaker 6r.tindertaker
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 YELLOW Family Copy PM:Crematory Copy CUSKM Rev.4/96
AUTHORIZATION FOR CREMATION
I F:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMP RA AND DISPOSITION
CREMAT 03lRev.4/9g
ION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLYCBEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority, ItNING CREMATION.
priority right under state law,to authorize the cremation poq�n
(hereinafter referred to as the"Deceased"). 9 Processing and disposition of the remains of an owl n� ving a son o
max. a serior
ame o ecease G\
I/We hereby request and authorize Death l
" � In Time of Death �,
Possession of and make arrangements for the cremation of the remains of the De =-' A.M. EM
ame o unera ome (hereinafter referred t0 a5 the "Funeral Home
(hereinafter referred to as the"Crematory"), ed at ")to take
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the Possession
amen rema[ory
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated reand Possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition
of the Funeral Home.
Deceased as follows: mains io the deceased are returned to the
Is specialhandlingrequired? ❑y� P of the cremated remains of the
o Describe
Description of urn or container selected:
❑ Deliver to Suitable for shipping: ❑ Yes ❑No
Release to family ame an ress o eme ery
Cemetery
❑ Scattering at sea by Funeral Home or Funeral Home's agent ame o esignat amp y em r to eee,ve rema
ema,ns
❑ Ship via U.S.Registered Mail*
To:Name
❑ Other Address
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with th
Postal Service.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed , e United Sta es
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and tote follow'
1. The remains of the Deceased will not be accepted for cremation unless received by the Cremator in afc accordance with
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and conditions:ytr
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 materialsother
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation e
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in an wful
manner it deems appropriate. container. �.�
�. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers,etc.) may create ay lawful
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain an type
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we herebd .�
authorize the Funeral Home itsY YP of �'
prior to cremation, and disposMa
t ema its iscretion. I/ E HEREBY CERTIFY THAT THE REMAINS ovean such mechanical devices from the remains oi the Deceased
DECEASED DO ❑ DO NOT ❑ C'O OF THE {
AIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial on
Listed below are all implanted mechanical 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: >w.=
Description of Implanted Device j
Disposition
Description of Implanted Device
-.W.Uon
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home -- . ,The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be tbfmy and
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory too en the cremation
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough
cremation.
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.Ike 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.
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. -- _
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. w
Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceased in a r
container which is not designated for any type of shipment.
In the event urn d ponntaiiner i insufficient to accommodate all of the cremated remains of the Deceased,any excess cremated
PG ti�
�4w AUTHORIZATION FOR CREMATION DISPOSITION
F:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNIN ',CREMATION.
031Rev.4/9S
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFU
FWe,.the undersigned,certify,'-warrant and represent that Uwe have the full legal right and authority,and y BEI-0RE SIGNING.
priority right under state law,to authorize the cremation,processing and disposition of the remains of
ow n ving person wh a su erior
(hereinafter referred to as the'°Deceased"),
ameo
I/We hereby request and authorize Date of Death J � +
e Time of Death S �
ner.
A.M. ' 1 P.M.
Possession of and make arrangements for the cremation of the rameemains uneraof
a Deceased at Berl afte, rferred to as the "Funeral Home")to take
(hereinafter referred to as the"Crematory"). V tl�J[j�J
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the
Possession and custody of the Funeral Home.UWe hereby authorize the Funeral Home to arrange for the disposition of the cremated
Funeral Home.
Deceased as follows: deceased are returned to the
Is special handling required? ❑y� / < ated remains of the
(�No Describe
Description of urn or container selected:
❑ Deliver to Suitable for shipping: ❑ yes
No
Release to family ame an ress o eme ery Cemetery
❑ Scattering at sea by Funeral Home or Funeral Home's agent nNeill ifia i 11:1 15 em r to remat emams
❑ Ship via U.S.Registered Mail*
To:Name
❑ Other Address
=111I e and Crematoryresponsible for any loss or damage of cremated remains shipped via Registered Mail with the United.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be pperformed in accordanceSues
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the'followin ter
I. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, with
eak
resistant,rigid cremation container.The Crematory is authorized to remove and disppose of handles ornaments
and conditions:
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
r
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation contain
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in an lawful
manner it deems appropriate. container'
2• Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard1
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type 0 '
implanted mechanical or radio ive device. In the event the remains of the Deceased contain such a device I/we reb
authorize the Funeral Home,i a en and employees,to remove any such mechanical devices from the remains of:the Decease
prior to cremation, and disp s o h items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF fHE
DECEASED DO ❑ DON T ❑ C TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial bite.
Listed below are all implanted mechanical 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
f
Description of Implanted Device „
Disposition
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral ---- '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.Me 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. p ough
Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillin s 'ewelry,and other personal ,�¢
articles accompanying t�Ie remains of the deceased,may be destroyed during the cremation process. e 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.
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.
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.
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.
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 Find•u.--