Gardner, Richard �o q4N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director5;lk ,E 70—/V
N a m eg/�Cl�f7/[�f�/l„I/�/I�,�/� Case #� /
Date of Cremation 9 - 11— o76C)6
Time Cremation Started 4 j�& 1TfM
Time Cremation Completed D r PjO 0- rM
Type of Container�Vyc/67// 6�/1 ,(CT
Remarks :
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TOWN OF UUEEN58U"Y
PINE VIEW CEMETERY
CREMATURIUM
Quaker Roadt uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or If no answer
Cemetery 745-4476
AUTHURIZATIUN TO CREMATE
The undersigned requests and authorize! pine View Crematorium, !n
accordance with and subject to its Rules and Regulations to
emate the remains Oft
(Name 1 (Seat)
' (Street ) (City) (Stet ) (Zip Code)
who died on � daY of
at — J5�-S
(place) (Address)
Name and address of nearest liVing relatiVt or name of pertoti
authorizing cremationt
(Name) (Address)
Relationship to the deceased
�N J
Name of Funeral Home
IMPURTANT= knowled a tht deceased has or
I represent that to the best of
my (Circle One)as no pacemaker in his �
.or he od.v"
I certify that I have the full power and authorization to arra"
for the cremation of the remains Arsonad to l direct
possessionsshavetlOrl
eithet
the cremated remains, to and agree to protect, defeat'
been removed or mayany and
and save harmless
lossPine
or damagesewhichimayum fbemmade again
andbl'
and demands for
reason of whethernsucl-td with claims orthe
demandscremation
areoorsaare not awholly
directed,
undless false or ram ulent.
i n ss) (Address)
(g gnature of via or Legal Rap. and Address)
Signed on this dater ��
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify: Id
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
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 of damages
whicih,'Attay be made against them by reason of or connected with the
cremation . of said remains and/or disposition of said remains as
directed, whether such claims or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
accepted.
S . Unless other arrangements are made the cremated remains will be
mailed via Registered U. S. Mail within three days of cremation to
the funeral home handling the service. There will be a $20. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 . 00
Children (age 13 months to 12 years ) $115 . 00 Infants (stillborn to
12 months ) $75 . 00
* Additional $50 . 00 charge for cremations done after 3 : 00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .
"Customer's Designation of Intentions"
Name of Deceased-:
Cremation:
(Scheduled.Date) (Location)
Manner of Disposition o Cremated.Remains: /
ZBurial at Return to Family
❑ Entombment at - - ❑ Other (specify):
t !:
I hereby designate the Disposition of Cremated Remains and acknowledge receipt''0"a'Copy of
this form. s
(Signature) ,
(Printed Name) (Relationship Jo pia
(Address) ti 3? 11 5s
(Telephone Number) s r -... r'
"Cremated Remains which shall not have been Claimed wiflui 1:20 r f the 4ate of
b disposed f b th• by `p C� ,, ��frfrl ki 1�f3A
Cremation may a is ose o i� rm ' aacement ' A- 0 .1 .. aritim:
k.
Printed Name of Funeral Director Signature of Funeral Director r+ r e ate `
or undertaker or Undertaker
t. .-
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 Pierson Malting Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSMMN Rev.9J96
PG�4�C
o�4w AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. w �
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,a ono of no livi perso o h su el
priority right under state law,to authorize the cremation,processing and disposition of the remains of /G�j1}� ?�-
(hereinafter referred to as the"Deceased"). �°a
Date of Reath me of Death A.M. ❑ P.M.
I/We hereby request and authorize —'z�./ E - l= (hereinafter referred to as the "Funeral Home")to take
ame of r uneralome
possession of and make arrangements for the cremation of the remains of the 4eased at
(hereinafter referred to as the"Crematory"), Name of Crematou
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 cgst4dy 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? kfYes ❑ No Describe
Description;Turn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Cemetery
ame ress Cemetery
❑ Release to family.
Name of amp Member to Receive Cremated Reiams
❑ Scattering at sea by Funeral Home or Funeral Home's agent
--E Ship via U.S.Registered Mail*
Tb:Name 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 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;rigid-crematiWCUtifi Fier.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 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 implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
when plache-eremation chamber. The Crematory will not cremate any human remains which contain any type 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 oithe Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASI✓1"Z DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below areAll iy iglBD.ted-m clianical.and radioactive devices which the Funeral Home is authorized to remove from the
remains of the�eceased prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
n -
Description of 1 fkv,ce' - "- 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 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.
Certain items,including but not limiteh to body prostheses,dentures,dental bridgework,dental fillings,jewelry,and other personal
'.rticles accompanying the remains of the beceased,may be destroyed during the cremation process.Me further authorize that if
airy 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.
"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.
,�. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverized
to an um entifiable 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 Deceased in a
container which is not designated for any type of shipment.
y. 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 primary urn or container.
,4. Me understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is