Gilfoy, John rrO` +N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director _
Name Q ��Arbj Case #
Date of Cremation 'z 4 v
Time Cremation Started 91M
Time Cremation Completed /p2l ��/� 1
Type of Container
Remarks : ^- 1C
��%�s fn�
R-S-electronics 5083784280 P. 02
SER..VICEQCIPP INTERt,IPJ PAGE C"
TCJNN C)[: PUEENSDUIty
piN[ VIF-W CFmETtw1(Y
6
c nL""Mt-vru tt I tim
Quaker Road. Qtuv nsbury. New fork I2804
Phone (516) Cr'emator'ium 745�-0477 or if no answer
Cemetery 745-41,76
AUTHOII I ZnT ION TO CIAP-14AM
The undersigned requests and authorizes Ping View Crematgriumt in
accordance with and subject to its Rules and RegulatiQn5 to
c r Q m�a+,,t a the r,eR!Ains qFt
ttaama)
(5tirKeti tCtty) (State) (zip Code)
who diets on .�..� dryat
(Place) t ddres5l
Name and address of neatest living relative yr name of per•sur+
aut)tiorizin� crpm�'+tifln :
(Name) (Addy 5)
peiatintlship to the deceased
Na nll3 of Funeral Home
114ppATANTi the d9cease0 has or
I
I represent that to the bast of my knowledge,
has no pacemaker in his or her body. (Circle One)
�
Iertlfy that I have the full power and -aut:horizatiorn to arrange
8
for the cremation of the remains
and tv direct the disposition of
the c;reslatiRd remains, that any ppr5onal possessions have ei:N;er
pegtt romoved Or may be destroyed, and agree ly and 40 protect, dpfenti
MS
and save harmless Dine View t-em"Or' m from Mal againstithem itaY
and demands for loss or damages remains as
reason of or connected with tho C►r�reandsoareoorgaare not WnVIiy
� rQCt4 d whether such claims or d
d +
undli:s t false o f audk%lent.
tW tees) / (Addr s5)
and Addross�
L 1 Reps
5i na►turte of Ftelativs or1 9
9
i g n e d on this d a te=__._._._.
9Z 1 /^Pn,2 ._:=0 513-7---0'C5 =EnVICEC!)RP :r:ix'P.J..T i%G5 E5
raeose „man crn<,r�..mc,•�„xa.er- • '
AUTHORIZATION FOR CREMATION ANi>DISPOSITION
L�j't71'[C{,:TDI3(SAl,lt(3AL DSL'L'htl'Nt:rI CONTAINS IhiY(Mi[A`rr!'3tVVt51<)NS CrXa('[RNI.ti[;CXLM.9TIUN
��PfRF.hiA'I'ION TS ixxBV CliSllfl_-...tLat:.aNtJ PIr+AI.YliAU7"ItSo IYI+CUn1P:.ti'I t'Aitldl Ol LY hkeUl21:8[rhEN,;. ___��
VIA.,floe Had tcprram Ibaf 11—Itav!die pai lsgm right And.hta.rM,alutikav' Moo prrrot,I s a eu J-r
pr wrn)nithtunde:uet¢`ay�.IeauUaurimtlu rte 110a.1,-001199 and 61*0,'1-ofthe re—l>ef=,_1 �'-'1
fh.relaaRmr rtferraJ to Bs wa•'Uxeased"f. 1
c 3 r)at DtXiy` 4 _;t...r.do.mn
1,^Vt nefeb)ngvilst.nd auderird „-_ l�sy_� _ r_,'I,nrw<rc nfW¢fine"t'vn•rs:Hume'f+u oaw
pasrenfon v£aad b,akk:�rtr.nytntrntt An'dXL'remede¢ol dW r.maN,+Oftf'fLaeaa Jat�✓I � '.VI
9uretlnikr W.rrgl toil.eh."Crenmbuy -
11Wt hertbv autherixe do,Cr,nadory to re,.the.remetd rtaani^s d III,deeeasei to m••p.,....Ilan a.a cafmd)of ttta Puue-'.i Hone.
Mil.InIZn.nd that ps.—does and abliyfll"Li at III,Crommw'y ehBa be fnR7a„d when:br«am. .d—.H.or the deuaud am W.—d ru tN
pro ii.and rwe.dv 4if,'rwm.l N—..Ill.bdr.by Wjj,,,ia¢dye Funsrut Prom.H,mraagr M,the dlapadfion ei 0 annated remain,yr It,,
D,—S¢d As bIll—
(srpraeulrandlmgregrtvedY U Y. —_-__.
1keaK)ptb,l al aYnoi CpdMH.f bth 4tl:^_-__-_�-- •__�'----_.___Sulmule fur Wl'Ppka: a 5ln . ..e
,kfxekarle,)nlyZ
S—tednt at sen by FWrefal fiat..ar Fwlor<l Hom.'aagrpt
7U:ladme '-ddttaa_ ......--_�—._..
tltnPia aX<XX�.1'<mM'far7.renM;espalel!P i:,nJ arlw 3.15hY Uf Gt.aB�lf r.ara�r,r.>�.prJ,ta�erafi�il�eh ihe�n c�lB:os i �
,file crnmafion,proc<isiu¢and dlspoalflou of the remains oP ilte 7lcaaaod aolhorized acr<In shall b(perinrnaed in arLar`d+ndtti"i,b
all Qawening IXw.,tiw ruff..,rega'atians Pad policiae of flit Cre,naw,y and Ruuar u1 Howe,and the fo�lat i,ii>enn•,n
7 he remains of file N"llaaad vvi11 but be accepted for rrttaagau unless recel,'ed by hic Crefeatory in a rmnhuatibie,I-A
reststanr,rlppid rrcmat Wn coatainau Tha Cremattny la authorized to crnsove and dt5hlose o:bendles,ornaztuu and a.y utty.r
noneomhuBfeDle Hems attached:a Qts ire mutton contahner prloc a rrerailion.In t7,.eouai day remain+uf ih.Deeexsed are
(reeaH'ed 6p the Crtuiatary In a wrtez nr stl,er container ranetruetad oP mewl,liharglnss,ar other nunta'nLvstill a mate'W'.
]ewe authodme the rem nsv/Ilia DeraJac:`.iob.remor'.d prim to Cremation ae:d plo:±d tnaconrbuttiLir t In n`em.tt.coautintr,
SrtVe fm tiler nutbV<lat the Funtral llv^�c ur CrrnlBtm y w!n:-ha dispdshput of am such nancbtub7>tp,ic ra,i:e any 1B+°eW
nunner it Uf¢ms tpprapriato.
1. M<rbanlcal or radiomefiye derieac lanpl.ctdd la ih¢re.stalas ut the Dcfeased!slosh+a paretn.tkcr s,EIf.J may real. Iy,wrd
Hewn piawd in the crentntfua chamber.the CramAtor�wail not rrewate.up human nniuib5 u h`it,ante" ann)< re L )of
v
unppidtttld ni..hanleal ar radioxti:c dtvicr.fn Pile e"<a inu r.tr:aim of fhg D�rwased cunmin:uch u deeuWe ht"EU
authar izt the Funeral Hofne,fa aycnu do.",Gtlployew,w rmno,a nnyySuch mnrJ,ult.a)dLYic,a fl ant!Le re+^l iqq It sere D.ee.a:E
pawl to f"w+a buu,and dispose o,such ittms at Ifa duu'euun.L'WB HERECY CCRT1F9'THA)'1'HL'itE'h1A7 S OF THE
DBCEASEA Dt) 1 DU NO,f' frC1N'fAIN ANX TYPF.Up1:NYLAN'9'EU MpCH�vICAG Ox RAD10AC,ftVx Ue.\'ICE.
Pleme initial Coe
Listed l,e1Gn a,'e a;imGentW n:ed r,!wl and mdloactlr:de,ie=r..rhieh 1:e Fwra,'at Harm is autl:arl't)w remov<f,o,n the
remulnt of the,filet... prier to uemu8nn,and dlspase Cf os Indhnfed:
Iftnv In.0 uaiou fm diay)udUmt b gieen,sueb toms may be dinputtd of at ore dish Nr..:cP the Funeral Honra.
J. Thai eUnwintr c'untalnin the r¢ur+lu¢of Ilit Ae.ea.ed a Ji b=pens<d to the cren,a(:ar chnmbu sod,III be w/a!I>So,
brts•¢r.IEdp Jeetm)ed hyprolum,tT.XpHAur.!u Satem¢htat and dirr.d tlahte.l+WC Cift'rvnce tlrc Crn,:atory,o o�'nth.ercmxm"
chamber during eat Mmulion pi'MIF and rapuaidon tho re4vai,,,or the Deceased,a order I.fall 101c:wrrp ek and thor�at*
Cremalton. flillm
a. .'SIA nlae:nytnc)ndig .)e110!l.ailfth-D...ed,6tl-:W'deSILM:gdErtialg:o,i-nrhtlinig c"s.t c„rtr e,va othn'pedlutil
uliAes aconnpaU)•'h1g�Ie Jeruaioa of ilia Deceased,nail•b:de¢ircyed during the cwmattnn proses I, e turtircr nutlrotiae lhatU
am'penis,otdtr I`las ttm ertmated reniallis of dae DeftAhe",nit mnvvered A—,flit eremalioU thrruber,tile"Indy be sepal sled
Iran tear careratxt rc W1111 of the D=teatA cad dispoeed of by rife C'remator'y
I4Ve herb,,autbartt.the Crermutery to,tp+rate and re!no.e ff�rn the efol-liar..ill runs'aU nrweombc:liblc r+aterials,ia,iudrog•
"� flat t:ot iimlted ta,binges,tAtchts.r:aas.lervehy and incuiws r,:•W1a,and to dicprse o(such n':aei lase,
Gollowin'•cremutlen,(Ue crtnfale;'en:attu of the Dacawed,<nsI Wit 0 primnril}or hw,e frngnr.nls,w;ll b:+ne,bualrally puls.rired
to 41157Uni'dtntl(I'+I Je cuns'istency pJ'+or Ira placomeN in nn am or otner cunt.me,.
coral a.'"nr b 1"I'l st"W"nfr ui ptf,,e of ihpp thaatd,[It 0--tvey rvht plcte Pilo crebietM t e,n..ms of rile Uer.aesM 4n a
n. In tha avenl the urn er container tt intutli,kni to accwtunvdyte all oP th¢c,e:n.dd,csaius of lb9 Deuased,any excess cren,attd
remahts v;U1 Le placed in a secondary cnntnlncr and I etustt.d W the Futiviul Home,Wiled-,vith the pria,ar)urn or container.
o L'VVe nnda;naie and ac}.rvw!Cdyle•,thatoIln,with the exn'CUC ofrt'asunabfe tare and Pile—of the CremreW,'A best elform;,t,
not pobs,Lle to ceraver all part!,os of flu cr Caiated renta:as of e,e 0"LoLlCd,oed Q,cI soy„e I'll,ti,leg n:h.!load""Ol'lly fee u,m
v.uneinpted meth tiartkitS of olher c,erlla4'6 rrnigiel,aH.aln;:vt i,t a,c cr¢u�alinn t:m:ti..t•m,d/.r utber dr.ice,u.il!rd to prop.:,
fate.Uelaafed.".ilia.If We her rby autltar!Ge the Crr.malo,$:v d,spus'e of aT,y,u,h residual partiett.In cal L.oful
mtnmmfr'�
dees apprvprhue.
IU. L'af.Fs I'A."Ire fillet IIll%Itit1,fr:511 uclioa9lh IIfIt AliQoIA1:lt,,u,tLa CI1-:11^n,p,ac.ss!ng and 6lspoh.If ,I the'0"k,s'r e„
pmeeaxd wl�not be pc f^rnmd-itds ata'rdancc wfill oil)par jtrular rellxiio „r memo: tunr mrss. ,
.. la the eYlAI In!Ct et714rtd r.117ai b G(£he Dr%1d.td rtmaln li.Wilhocd hrr n p"led of}n days,lE,r Funerdi H.ore;hall give wl lt•na
notice W meitt9 y)'c.r11fl94 aw I of the edJreatlesl lhdkattd Wloo. VV4 Hurt¢ttwt In the event the rrtrutri rr!naim of I,,
Pereased rclnunun.'.ainfed.scrappe;fed oP Laidays idhf the date' h•ei,ttsst nnttUcaliacsmeYcd,Utepa-ral Hamel N'atvuth"ie'd
ssnd d4lCold to disp'•st of the UnNain:e(!crn::atcd remalm Ve i;,,Dece.'d i•,an•v 1,.+:'u!uteoner it roil•,d,zm+fWr^p
i. PNenyrmtbindumnify,rekrasc"Al•old l;Ir Gremurnl•yFu,rd;".IH—.'Own aUJUrR•,uaenls,cmploft ea and al ign:,h.n:9.,,
fruat any and all 19cs,dam a gem,Yet,i V of C a 1w5 of Action it llQ.aoc aa.if tel'd arr,LCU:nx•9 JP tit:yyatmmin ccmertlon,u'i'.
tau!,Ieuwtion mild dapoodion oft.Ce cr tA.a:a!i l.malas 0r 4'.e Dee;t„tI usaull V,-.it be.lin.;r m,four fallow to col veal}idnmift
the rena;.s of:lie D,.mAa,d,diaclrae tht pfesenea of ant huplanRd a;t'll-CHI a:rudivactive devkcs,ur tali.possae;tnv lore^,
make penna.tnt arrallgemcnis Par,tJ,e diepca!tion of aud:.duams.
f3, I,xct eplri set tur(b in this.lanavri.abne,ea, arre,tieF,expreyeto nr hnplicd,:rtcr.W,b;.'ihc Funeral Hance,(atrnxo,,r,oram^f
Ctrir r es;+ttttre aERi:ates,asenll,a'empin>cc.,. pt xss
7. Il1k'a uadmstmtd that tbla ducumentdocn al cmrtulm aeongslety and de,all..t 9tsusoana J'ev�av atpdelof wecro,uafn
Y,ae Ukno'.vledg.rdydana,front A,t Fune•a!HVn1t',a a,pi o.thil 0uokla ant`(id"l,mviallon TacrA"Cwdalnlp)!h a&Slil.rol
Ir
tkp!anntor v inrar•,aat:on about the cn.maUun proses..
SIGNATURE OF PERSONS)AUTHORIZING CREMATION AND DISPOSITION
t1k ,arrant that nil rQ1,1CSenlatians IoI stao mmllt,,loud!h.Mn Hilo flue and carrrct.and thal Irwt h—.cud an++.,^dent—I I,,
:Jro-'isivm contaygd�n ins uctanen4 atW tic^L"+,c have moeir'he b"diNt entlileu"+=r.,nalran Eares'.
Q, ffIrt'*';Q let —
,y — g �i�ld�_;,,��:f�iZ�--.--- rvP�roi':.•;�+.�'_..__— "
� SX `l .f, t�71e1.Jlrrv(aG�li 'Pu.�,,.r£ ��l� fCo
13dnro1s
G ,'. tlr�1 r,.•„ �� r r __.!/'�i.Jl!._r/'� ��-ijr —<" ``��E•.,�u
RiS-A 1 ecc r on i cs 5R+837 B42 SE'� F•.he,
F't/12/«F'�� 1x:2® 5':s-?3�'Z�:�JE SERb ICE9C5'P _hl"ERlU>' PGCiE fit,
• ',`.Tanxc o4Ct.tnrteiy,�Fta�,era�l�c:xr.«. _�/t/�e�.�' � �_��=��,�------ ---
r
RF?C:1:IPT OF CREIAATVD IZE�WNI AND RELF..ASI~ OF LLABILITY
el , a
' l'He unci.rs:gneaJ}.erab)'Ctt4iiy tl=nk ib-h—** e':epl might
yr to telto Custody anzl+a%At,di.epeezkion ni!6e cfeza7atefl raraair+s ui
the t{a:4aScci slip bezebv acknvw e e rooelpt of:hc Cxemat vimains C�
\r.1blE -)F hW
DE
CEDENT:�� }
TE.a u:,aeteigne,he tlu%assume ku)a traptYe:llii:y for tom nritvl srd pinon d�p6ail;iav 4 ea4 Cremsfe l renuSKe
The agree ha inde.mnily anti held nafmlee.ilia above x,emed corneteiyikunsral i+ome, its a¢enta at.�
arup:oyeae inxn any ane all liobli!y.inc•li;a/-g�eaao�wblo a'•lorn1ey i.,es,afitl t.�+aanst any loan it or ei+y al F1'ani may a�.staix;1p
CU:+nrati-,n vacl b!.e tecaipt cE,elaipztien4 Q{',of cremated—ire.
N,=rt1 ei,ilia abUV6 netz3aQ'emeiei�i�t+fl.Gxal itL:%i mall�0 l:el 4.a%rtlaas irof 1ny aelects[2 la 1�t8 of Any cGnta nCf T..vt
evp�4 e1}xy the ceznatm,iineral home
Zip
CireC! iw
�,`�i�a.tnie't-���• �.:�3 v L__._-.--�_.-._ is yip W pe�a3FPll `
Au�6oflxarl S'iep%ebez+}atrve 59N#�l:cio II}
4,g—t,t}z✓ `la.icnsliy� Dm;faaed
a SGtJ(#Pi U)
orcra reez;`atr:e`
l�pceaenletii'e }�ar,:etery/)"cner��+
1 ELLJW:1"fmily Copy x G8M C04 REV.?2191
D"f';iTc'Funeral Ho=ea�cpv
Yd