Jensen, Eugenia SOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�J��r/�/�p(, �,�/�/ �
Name � /�l/i9j11$ Case #
Date of Cremation p� `� 7` 0-7'coo
Time Cremation Started /���J Iq '/M r
Time Cremation Completed :S�rt !15—
Type of ContainerC9D
Remarks :
of
-a �/'q Im
�'% 19 /44
TOWN OF QUEENSUUIiY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT1•IORIZATION 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 :
E T
(Nam e7 (Ser<>c
8 d I f�144 5L C P i _✓i �a,e Y�IxT.6- �,.i��K3 ..e, �� --
(Street )--� (City) (State) ('Zip Code)
who died on /,$ day of
at
(Address)
(Place) , .7 q
Name and address of nearest living relative ur"t Iamvr`of person
authorizing cremation : ; „ .•; �,,,:; yLsl;p,pj
yc
(Name) (Address) ,„j;, bis )0
Relationship to the deceased 5 v>7 _
4.
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge.�l:.'tShrQ�+t )aic�1€ed', has or
has no pacemaker in his or her body. dC.ireler•.LIn�J» '7^
I certify that I have the full power and •aut:horization to .a6rrange
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 remains as
directed, whether such claims or demands are or are not wholly
groundless, false r r ulent.
K"
it ss (Address )
(Si atur (of Relative or Legal Rep. and Address)
Signed on this date : / —
1,N & DENNY VIC%
Qhtecasbttry, Ntw YaA
"Customer's Designation of Intentions"
Name of Deceased:
C,
Cremation: 2,1) L- j1) r} J/j
f / (sh.".a Date) (Location)
Manner of Disposition of Cremated Remains:
0 Burial at )'Return to Family
El Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form. ---% I
( ign;b—)
(PW.W N..) (Relationship to D---a)
07
(Ada-00)
V
28,0.5- cop
(ir.I.Th..Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Named Funeral Director� Signature ofT-w=al Director Date
or UnjeAAer or Und"ta6r
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:. (AxwJ Date) (Location of Crematory)
Disposition of Cremated Remains: "..r d Disposition)
(Date)
Na..of R"on MA-4 Diqmntion SignatureDate
#9 wHrris:Funeral Ho—copy YELLOW F--4 copy PUM.cmu-tory copy CUSMEN R. 4R6
/�4 -
AUTHORIZATION FOR CREMATION AND DISPOSITION 03Mev.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.
I/We,the undersigned,certify,warrant gild represent that Uwe have the full legal right and authority,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"). -Waint of ece
stsed
Date of Death D Time of Death A.M. ❑ P.M.
I/We hereby request and authorize ,., f„Y, I(-' t.}- (hereinafter referred to as the "Funeral Home")to take
ameor Home
possession of and make arrangements for the cremation of the remains of the Deceased at P-, ,r,e U,e_i,� C,r c r�w�Or>
(hereinafter referred to as the"Crematory"). ameo rematory
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
❑ Deliver to Cemetery
ame an ress or cemetery
❑ Release to family
Name of gnated Family Member 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,rigid 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 cremation container
I/We further authorize the Funeral Home or Crematory to make disposition of any such a,-, in airy iavv
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 placed in the cremation chamb he Crematory will not cremate any human remains which contain any t
implanted mechanical or radia devic . In the event the remains of the Deceased contain such a device- I/we If
authorize the Funeral Hon3i *711einvts and em loyees,to remove any such mechanical devices from the remainsA�thprior to cremation, and ch item at its discretion. I/WE HEREBY CERTIFY THAT THE RE1111 NSDECEASED DO ❑ DNTA ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVV
PleaseListed below are all impinic and radioactive devices which the Funeral Home is authorized to 0J.remains of the Deceased p ion,and dispose of as indicated:
Description of Implanted Devitt Disposition
Description of Implanted Device Disposition
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. r ,,
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and wi
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to operrcf_.<
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and lgh'
cremation. -
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings ewelry,and ot9:er pets.:.al
articles accompanying the remains of the beceased,may be destroyed during the cremation process.IAe further authorize that if
any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may bhs eparated
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,iwjli ing,�
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 mechanically ppRerized
to an unidentifiable consistency prior to placement in an urn or other container. =r ,:
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceasta6 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 cremated
remains will be placed in a secondary container and returned to the Funeral Home,together with the nwimary urn or conta_into. '
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is�
__ _ _ n , — • __1 . ____ ...._., ....=.l..n..♦o..41v hnnnrrmal