Guthrie, Richard rrO`74N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name j (J � GofihF. \ Case #
Date of Cremation 1 M (a -
Time Cremation Started 0 V:A -,IVA
Time Cremation Completed i 7(2 J
0KGjq5r
Type of Container �-( (�(�,�� e,c -✓ 1
Remarks :
LA' 0 L) F-
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_ Jo n-05-00 12: 52P Chris Guthrie 703 237 5443 P.O2
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TOWN OF dUEENSDURY i
ptNE viEW CEMETERY
a
C14C-W1TOR tUM
Quaker Road, Qveensbury, New York 12604
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT(-10121 ZATION TO CREMATE
The undersigned rv4ue5ts And authorizes Mine View Crematorium, ifi
accordance with and subject to its Rules and Regulations tq
cremateQthe remains ofi
_ t1l.�c► 1'Y1 —T
(Name) t5eH> ,
tStr■et:) 1Zj-
V tCityi (5 ate) clip Code) i
who died on �� day Af =f=rr_ -2a12 �pf
at G1 nj &IL �es»� a1_ -
(Place) (Address)
Nawf and address of nearest living relative ur name of persornl
authorizing cremation:
l Yf.�+1rt���Lx T l3 r x
s
(Name) (Address)
i
Relationship to the deceased Ste....
Name of Funeral Hope
IMPORTANT.
I represent that to the best of my knowledge, the deceased has or,
has no paceaa6er in his or her body. tC_ircle One)
I certify that I have thy full power and authorization to arrange
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 prateet, defend
ants save harwless Pine view Crematorium from any and all claims
and demands for loss or damages which may be made against thism by`
reason of or agnnetteC with the cremation of said remains as
directed, whether such claims or des�ands are or are not wholly '
groundless, false, or fraudulent.
tW mess)
(Signature of Relative or Legal Rep. and Address►
Signed on this dates ,.?hs!�
Jan-05-00 12 : 53P Chris Guthrie 703 237 5443 P 03
lj/:"- b18-732-1297 REGANU)ENNY #1346 PAGE @3
-0o
AUTHORIZATION FOR CREMATION AND DISPOSITION
NOrnC -THIS IS A LUC.Al,DOCLUENT-IT CONTAINS IMPORTANT PROWSIONS CONCE&NING,CREMATION.
CREMATION IS FRREVERSIBLUAND FINAL-READ THIS DOCUMENT CAREFULLY BEFORE SIG.NING.
IrWe,the undersigned,cwtlfy,warrant and rtpi,estat that Viva We ft 110 legal right and sathorky,and kwm of no living Person who has a superior
priority right under state law,to aoshmizq the cremation,processing and disposition of the remains of '&Ghao- Q W �hrl C
(hereinafter referred to Is the"Decested").
rim at vea th
VWe hereby request=d authorSse r r ?qoo Time of math j,2 Ablj -RX
roll AL-2 Torsi
thu - �1 QWFWWX cc
possession of and noict arrangements(fir remation et the retrains of the Deceased at ejj2r brie IJLI
(bovinafter referred to as the"Crematory"?.
IlWe hereby authorize the Crematory to return the cremated retrains of the deceased to the possession sod custody of the Furletal Rome.
I/We understand that the services and obligations of the Crematory*%9 he ftMtkd when the cremated remains of the deceased are returned to tht
possession and comedy of the Fuserai Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the civosted relmAss of am
Deceased as
l6bpecialband- r9quir-d? n Yes .Nf1N9 Deuxibe
DeKr*im of two or container selected, _Suitable for stopkW 0 Ifft jil No
0 Deliver to
0 adefift to family item W7 pw~ftmly Akew 110 jKawvi c-a"Oed FAWW"
n- scstiarkne at sea by Funeral Home or Funeral kjome%agent
Cl Ship rim U.S.Registered Mail*
To:Nam Adkiress
7 Other
FuneralBoom andCrematory am not responsible kr-any ions or damage o1crews"remalwslipped via"istered Mall with Ualk-4 S#Aes
Postal SWV"
T)4g cremation,processing and disposition of the remaWs 91 the Deceased authorized herein shall be performed is 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 bt accepted for creawtion unless received by the Crematory in it combustible, leak
resistant rl id cremation covitainer.The Crematory is authorized to remove and dispose of handles,ornaments and*oy other
uoucomiQble Items attached to the cremation container prior to cremation.In the event the remains of the Dectased are
received by the Crematory in a casket or other container constructed or metal,fiberglass,or other noncombustible s$sterials,
I/we authorize the remains of the Deceased to be removed prior to cremation and Placed to a combustible cremation container.
I/We further aulborizo the Funeral Home or Crematory to make disposition of any such noncombustible casket to any lawful
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased(such as pacemakers,etc.)way create a balard
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain anj type of
Implanted mechanical or radioactive device. fix the event Ike remains of the(Deceased contain such a device 1/we bereb
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from tilt remains of Nceasei
prior to cremation, and dispose of such items at its discretion. IAVE HEREBY CERTIFY THAT THE RENLUNS OF THE
DECEASED DO n )DO NOT 0 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE,
Pkan initial one.
Lined below are all implanted mechanical and radioactive devices which the Funeral Home Is authorized to removeffrom the
remains of the Deceased prior to cremation,and dispose of as indicated:
DWrwft Cr Impbo"Devine
If to 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 beat and direct Rome.JVWS authorize the Crematory to open the oreniation
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a iompleft and lboteuxb
cremation.
4. Cgt1ain items,lacludin but not limited to body prostheses,dentures,dental bridgework,dental fillin ' a[ and other personal
Wme ;Aer autherfix that H
articles accompanyingilhe remains of the beceas4 may be destroyed during the cremation process. farther
goy items,01 0 the cremated remains of the Dft�eased,are recovered from the cremation chamber,they may be separated
from the cremated remains of the Deceased and disposed of by the Crematory.
5. Me hereby authorize the Crematory to Separate and remove from the cremation chamber an noncombustible materials,including,
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
.. r. . .fan-05-00 12 :58P Chris Gut;hr i e 703 237 6443 P.04
...,ww.a v.,..c,.c.+c.ocay%v,axa.our,prnurr,ry vl oune rragmenu,wtu tw mecaanicaay putt erelt
to an an71Arntifiable consistency prior to placement in an urn or other cotttair+cr,
7_ Unless as urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceased in
container which is not designated for any type of shipment.
9. 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 fa a secondary container and returned to the Funeral Home,together with the primary urn or container.
9. Me understand and acknowledge,that even with the exercise or reasonable care and the use of the Cremate ry's best efforts,it i
not possible to recover all particles of the cremated remains of the Deceased,and that some ppa�rticles may inadvertent become
comet agled with particles of other cremated remains remaming W the cremation chamber anVor other deices utilized o pnxn
the cremated remains, Me hereby,authorize the Crematory to dispose of any such residual particles in any lawful manner
detnu appropriate.
10. Unless I/we give specific written instructions in this Authorization,the cremation processing and disposition or pat remp=of th
Deceased will not be performed in accordance with any particular religious or ethnic customs.
IL In the event the cremated resaainis of the Deceased remain unctsimed for a period of 30 days,the Funeral Home shall gi a wriuej
notate to me/us by certified mail at the addresses) indieatcd below. UWe agree that in the event the cremated r+emajcs of tb
Deceased remain mwisti fed for a period of 120 days after the date such written notification is mailed,the Funeral Rome Is audtorim
and directed to dispose of t;e unclaimed cremated remains of'the Deceased in any lawful manner it may deem appropriate.
12, Me agree to indemnify,release and hold the Crematory,funeral Hoare,their Whales,agents,emsployces and assigns,harmles
from any and all loss,damages,liability or causes of action Ontdudin attorneys'fees and expenses of litigation)in compecti�on wit:
the cremation and disposition of the cremated remains of the Decease,as authorized herein,or my/our fatlare to correctly identif
the remains of the Nceased,disclose the presence of any Implanted mechanical or radioactive devices,or tape possession of,o
make permanent arrangements for,the disposition of such retrains,
13. Except as set forth in this Authorization,no warranties,expressed or implied,art made by the Funeral Home,Crematory,or any o
their respective affiliates,agents,or employees.
14. Me understand that this document does not contain a complete and detailed description of every as
ppeecctt of the cremating procest
U We acknowledge receiving, frow the Funeral Home, a copy of the booklet entitled "Cremation Facts1e containing additions
explanatory Information about the cremation process.
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSITION
Uwe warrant that all representations and statements made htrein are true and correct, and that]Vwe have read and understand th
provisions contained m this document,and that I/we have received the booklet entitled"Cremation Facts".
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WITNESS MP I/ � l�r,�,,��T � C .�
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web: ea7it11Mr Cm YBLLQW:Catna.ery Coy IML,ftm.il K*�coy GOLD i,pih Copy
'01-05-00 12:44m From-0 / NETWORK SALES TRAFFIC 212821F04T T-182 P.04/04 F-732 \
'. Unless an urn or container suitable for ase
meat is purchased,the Crematory wAl place the cremated renaltis of the Deced is a
container which is not designated for any type of shipment.
i, .din the event the urn or container is iumMcieart to a"vmvwdate 411 of the ereraAted Nr us of Ibc Deceased,any emss cremated
romaios will be pieced Im a secondary container and returned to the Foaeral Hoare,together with the prb wy Ur14 Or eontalmer.
a. VW*uuderstud and acknO rled ,that svea with theexe�W=of reasamble care and the use of the Crepes ' It Is
not able to recmr all es of the cremated remains of the �'Y s bee tlyb s,
�eonitud�agled with ]q�i� �and that somh particles may igadvertentl beware
cremated reuwith YQuf other emoted a the Cr sut{o in a cremation
f tion cbamber ana/or other devices ublized 0 process
deans appropriate,
Y P any such residual particlea In any lawful maareaer it
ill ;ve' a wrhttam bwuc tans in this Awhoirljsatlop,the cremation processing and dfspasltim of*a rein of the
D&ON wtinottin Pworraed in accordance with any pnrticulhr�eiigioues or aaic customs.
-L In the event the cremated remains of the Deceased remain unchained For a period of 30 days,the Funeral Home sball Sipe written
notice to jmWw by curtifled mail at the es) indicated below IM agree that in the event the cremated remiqns of the
Deceased remain unclaimed,ftr a period_ i?A days after the date such writto 6WIcatlon is ma"the Funeral Y is authorized
&ad directed to dispose of a unc d cremated remanns of the Deceased in any lswffvl utannerlit may scar appropsi0e.
,2. We spree to inde ,releasiee and hold the Crematory,Funeral Hoare,their at'tlliates agents,em loyoq and assigns,bar�rmless
tkomnany and all loss,"�es,liability or causes of action(hrdudin Otte, fees ana cacpeasens of litsgadoa)In emmeiavu with
the cremation and dtspostgan pf the cremated remains of the Deceased,as utbOrized herein,or myleur Wgurt to cvrrectil identify
the reauaims of the Peceased,disclose the presence oi'*alp irnplant:ed mechanical or radioactdve devices, or tape possession of,or
wake petimaent an"MVMtUts for,the di iposition of such remains.
3. Except u set forth in this Authorization,me warranties,expressed or implied,are made by the Funeral home,Crematory,for any of
their respective aMliatrs,agents,or employees.
4. Me s uiderstand that this document does not contain a complete and detailed description of every aR�`ct of the crenatatiatq pe�ncase.
ltlWe ackaro+►ladge receiving, from the Funeral Rome, a copy of the booklet entitled -Crem ties AI , containing dditionai
explanatory information about the cremation process.
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSMON
We warxaat*9 all representatilous and statemests made herein are true and correct, and that Uwe have read and uuder�Mnd the
romWom autnined in tbn�ia document,and that llwe have re Aved Ukc booklet entitled"Cremation Faets".
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t • `01-05-00 12:460M Fror-URN I NETKRK SALES TRA,FIC + 2120215047 T-182 P.03104 F-732
AUTHORIZATION FOR CREMATION AND DISPOSITION
TIIIs is a t.EGAL DOCUMt :zT t,0?1FI'AINS IMiPot;rTAN'e o slloi CONCI��O a ►tA°�xov.
C3REMATION IS W.MVWtSIl3l.R AND F NAIIr.RUD 1141VS DOCUMEITr CARBYVUY
JUW%the saderaigued,cerft,warrant and reps mi that Uws have the M11 Inal right and authority,&aid know of ovio
priority rf&uMer state lsw,to authorize the orematiwt,proces ft and dupe ift Otto rawidus of g O ban a s e,710i
(hereinatbtr releax'ed to as the"1lemaseda). •
U?ate of l?sath--�rl o o Time of peatt 91$
tf%hereby requM and authorize ,�q to NY
mWe e"oaf Land nub arraorma a Ror the u�eartation of the remalas orthe Deed art do
to take
,hwelaafter referred to as the"Crematoryl. �+
7We hereby nathortse the.Crematory to return the cremated remains or the deceased to the possesstoa*hatody or,the Faaeirid Re,n'�,
!/We anderstod that the services and obllptlwu of the Crematwry chili be ihlTQed whin*a cremated rsmaina1e de+ceeaed We reNtraed to the
mmsmM sad cnstody of the runentl Boma.IA''ve hereby authorize the Faaaeral Hoare to arrange•for the dippasi f the cmulated neat as or the
74censed ae taum:
IsaapeaWbaaaftrequh*d't 0 Yes X No Describe i
Deswiptiart of rant or ceataber sulscbd: -�SutGlir ahlppag: Y s�Rio
C 911111 er to t:uaekrp
m> a.��- be€l w�If Fe erne G cri 5
a —"
a scattn*at are by Funeral Hants or Fktgerai itonle 6 agegd �
i
C Sap via U S.Regista�od 117ii1*
T a Name Address
lJ
yWmml Now Md Crematory an not reepo@—Me fir any or damage a—m mimics iWood Yin
Postal MMIM
be crematiou,proMsing and diapositioti of the remains of the Deceased authorized!herein thou be p mid in wcordence with
l governing laws,the rules,regulations and policies of the Crematory and Funeral Iloraae,and the Poll terms and couditiowa
The remains of the Deceased will not be accepted for cremation uniam•ra:pelved by the Creme 7 in a comestible, leak
resistant,r'&Id cretaatioa contaivae,r.The Crematory Is authorized tip rantdv�aen dinposc of hanAl ornaments apd Oxy othear
a;oacombe bie items attached to the cremation container prior to,cremation,to the event the of the Dec*Wd are
recetved by the Crematory its tt casket or other container tcuctad of metsl,Iibergla ,or otl4e b is �t1,
rre authorize the raopmbuie of the Dmeataad to be removg or to creaq�atipn aid placed tea a eom raiser.
We further authorize this Funeral Home or Cremat*y to vaake dispositloaa of any such noncom tibW easltet in any lawful
manager it deems appropriate. ;
Mechanical or radioactive devices iin lgnted 1 the remains out'the Deceased (such as pacempake�y' _e_t'c. moy creaft a hatord
when placed In the cremation ehaat . Them will not cremate aot�lxunaaaa raaooialaatwnat comht' aP7 a of
impAited rahectihamical or radioac&*device. Ina the event tht' remains of the Deceased coutati eyht a deviQ��/`&���
atataarime the Funeral!Ho tsagos�ue�b is st tts'discreti vvvEueh rrt EYcal� ►T TFi �� V�OF THE
prior to cremation,
DECEAg - DO NOT XCONTAIN ANY TYPE OF IMPLANTED MECKA"OR RADIOACTIVE DEVICE.
Please initial one.OP
Lured bdow are all implanted mechanical and radioactive"ces which the Ftameral u9me'io naRtlaw ind to"move fig the
renaai n of the 1krem prior to cr nation,and dispose of as indicated:
vMu�oe,�etlgr►waeo a�wka altro,Waa
Dp eb"artnWlWWDada a7YaaAtkn .
If no lastructioa four disposition in given,such items may be disposed of at the discretiou of the Funeral Hattie.
The cremation eontatiaaer conta,�t the reraaittas of the Deceased will be placed ins ibK crcoaatio+a chamber aaitd ra►lll be totagy attd
Irreversibly destroyed by lairolaa'aaige�expoes�re to tawtarnse bast and direct flatrae.I1We aatito�s tiro Crematory to epp��u1 the crenuauon I
ebstnber dnsiag the creaas<tioeh prvcpss and repoatioaa the arut►aias of the Deeeaaaed in order to fxciiirste at copapleie d�RbbX'oltgb I
cremation. '
Certafa items,iacltmlin&bnt not limited to body Qrostleess8,dt:Wthres,dental btiaigework,dental ti1lfa ewe and ,personal
alttieh'd ticeornpaat g trie remalius u(the�kceaeed,clay the datctroyed during fttr creiouatton groaxss• a thrflter authorize that is
ax►y itmaa3,ottaer ow cremaud remsdrta off tibte Deceased ahn recovere419rom the eretruation cbaitlm6er,they mar ba 4eparated
from the c»anated reaamins of the Deceased and disposed of the Crematory.
�goi rolum W to,authorize
ImM latches,nTal to ts,�aa and precboafr �s eandd too dispose of$�itcl�a ro aas�tibls mate,rlals,iaoiudinS,
Fou?!r YY crernatlou,the cremated remains of the Deceased,cousW t�g prltatWRY of bone fragltie %will be mechairiicaeiiy'palveril:sd
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