Hermance, James rl-O W11 C OF QUEEVBUJ Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1-4 V zVN51
Name awx—,a— &xM&—egf Case # iZ<:'-�
Date of Cremation ��" �02` o;Z�
Time Cremation Started b r il(z
Time Cremation Completed rr �i9!
Type of Containers/?r 07/4/4j /�J` TG/�S•Ct
Remarks : ,
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
M
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 of :
(Name) (Sex )
(Street (City) (State) ( Zip Code)
who died on day of
at
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation : \'
&��- (�
acme) (Address)
Relationship to the ceased
i'
% Name of Funeral Home
IMPORTANT:
/ rep )acemaker
ent that to the best of my knowledge, he- deceased has-or`
as nq in his or her body. (C.ircle Q )
ify that I have the full power and •aut.horitation to arran6e
for the cremation of the remains and to direct the disposition 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 remtins as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
Witness ) (Address)
V (Signature of Relative o Legal Rep. and Address)
S:i/gg�nedon this date : ' J�
PG ti�
wow AUTHORIZATION FOR CREMATION
_ AND DISPOSITION
• �F.:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. 03]Rev.4/91
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE S
I/We,the undersigned,certify}warFant and represent that Uwe have the full legal right and authorit an SIGNING.
priority right under state law,to authorize the cremation,processing and disposition of the remains of
Y� w of no livin erso who has a superior
(hereinafter referred to as the"Deceased"). the
e o cc
ate of Death / 5\00'b
I/We hereby request and authorize a Time of Death
� ape � � ❑P.M.
possession of and make arrangements for th cremation of the remains f the Deceased at der V i ferred to�s the "Funeral Home")to take(hereinafter referred to as the"Crematory"), vVl/V
ame o rematory I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of me.
Deceased as follows: rued to the
Is special handling required? ❑Yes ❑ No Describe he
Description of urn or container selected:
❑ Deliver to Suitable for shipping: ❑ Yes ❑No
--�Telease to family ame an ress° em ry Cemetery
❑ Scattering at sea by Funeral Home or Funeral Home's agent ena amp y em r t° ``�'" remat 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 the United States
Postal Service.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be perform —
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and co
I. 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 conditions:
noncombustible items attached to the cremation container prior to cremation. In the event the remains of the_L�eany other
eased are
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other mainsnonco f the 1lerma ed are
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 im
when placed in the cremation chainplanted in the remains of the Deceased (such as pacemakeps,
ber. The Crematory will not cremate any human remains which con Y`type of:.
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device we hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains of;the Deceased
prior to cremation, and dispose items at its discretion. I/WE HEREBY CERTIFY THAT'THE-REMAINS QF THE.
DECEASED DO ❑ DON TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initia
ListedAe—
below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to retie-from the
remains of the Deceased prior to cremation,and dispose of as indicated:
Description of Implanted Device ' ' -
Disposition .
Description of Implanted Device
If no instruction for disposition is Dtioo
P given,such items may be disposed of at the discretioi�+�Funera'1 Home. :Y
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.I/We authorize the Crematory to open the cremation
chamber during the cremation process and reposition the remains of the Deceased in order
cremation. -.to facilitate a complete and thorough
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,d fill' s 'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation ►ngI/,W� t
any items, other than the cremated remains of the Deceased, are recovered from the cremation chamberf theyema 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.
S. 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 ere
container which is not designated for any type of shipment.
1. 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 nrimary urn nr rnntQinnr
RFCiN & DENNY FUNERAL Y'-RVjCE
53 QuAcr Rviwi
Qwen&Wry, Now Ycvt rn
8)'192-i 114
"Customer's Designation of Intentions"
G
Name of Dece ed: Q.- 4-k. t -3
Cremation:
i( helula bate)
(L-ation)
Manner of Disposition of Cremated Remains:
0 Burial at A-Return to Family
El Entonihment,at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and admowledge receipt,
a copy of
flue form.
(Signature) -------
(Printea Name) r Welations -tajDe—a)
L. N
(Irelephon.Number)
"Cremated Remains which shall not have been claimed within 129" "
cremation maybe disposed of by this firm by placement in a co
ti, IAI
VA '( 1 C"t
Printed Nam j of Funeral Director Signat of"M�- al Director
ok-tindertaker Undertalter
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION.,
Cremation:
(Actual Date) ql-cafil-Of C—tftloi:
Disposition of Cremated Remains:
(M.of Disposition)
(Location)
(Date)
Name of Arson Malang Din-aition Signature Date
#9 wHrrE:Funeral Home Cow YELLOW:Family Copy PINK Crematory Copy 6USWEN Rev.4/96