Macey, Baby TORN OF QUEEVBUf�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1?.�i9X V�NNN
Name Case #
Date of Cremation �L — 3 — oZ�gdQ
Time Cremation Started C;?'i4n rf pl-A4 I
Time Cremation Completed 02 17 -141 1PIM I
01
Type of Container ci9 �,��i9�� n� GS•�c�i�' �iT• ",Z77/��
Remarks :
TOWN OF OUEENSUURY
PINE VIEW CEMETERY
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 :
(Namu)T I Sex) - '""�
'. Lt�g519�
(Street ) (City) (State) (Zi,p
who died on nt.1 �1oS L4: Y,. "m90 we��--
n(4) day o f � n( �C} "�
at A AdV LVJ:;6 (GFEL /���At�lY � � ;�A .�
(Place) (Address) r� - " -
3 ri I
P1Trom9'Y
Name and address of nearest living relative ur name of pf r n
authorizing cremation : ' s
(Name) (Address)
art16m9"1 /►
Relationship to the deceased__ 114L:-1 ; _ Ti
Name of Funeral Home_ d�/=()�/t/�/ `�` 9� A<rtt�j� bra ni
IMPORTANT:
I represent that to the best of my knowledge, the dEceas'ed ?•Itias *&r
has no pacemaker in his or liar body. (Circle One) ' o
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to direct the disposition ;
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 or fraudulent .
(Witness ) (Address )
( ignatur of Relative o Legal Rep. and Address)
Signed on this date :
.53 Quaker Radd'
"Customer's Designation of Intentions"
Name of Deceased.: i �A_ i_ M-
Cremation
• 71K, C4 1 fit'. , 11 t L, 41
(Scheduled Date)
(Location)
Manner of Disposition of Cremated Remains:
❑ Burial at K Return to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature) 1 f
(Printed Name) (Relationelup to Deceased)
(Address)
(Telephone Number) s
"Cremated. Remains which shall not have been Claimed. within 120 clays from the da;a of
Cremation may be disposed of by this firm by placement in a columbarium."
is F I-1 j � `4 f'. 1 .a.--YL�..�I � fc D A'? _
Printed Name of Funeral Director Signature of Funeral Director,°
or Undertaker or Undertaker `
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 Person Making Disposition Signature Date
w
>r
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUMTEN Rev.4/96 s
I
QGNI.X1
�oo�w4w AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.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 and represent that Uwe have the full legal right and authority,and know of no living persoa who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of A- A A ItIV11 g y
(hereinafter referred to as the"Deceased"). /� ease.
Date of Death / ame o ell Time of Death 3'36 F-Y. A.M. ❑ P.M.
I/We hereby request and authorize �� [� /��/`- (hereinafter referred to as the "Funeral Home")to take
-Fame of r une Home
possession of and make arrangements for the cremation of the remains of the Deceased at 13-a V/t-
(hereinafter referred to as the"Crematory"). Name of Crematory
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 A No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑ No
0 Deliver to Cemetery
ame an ress o cemetery
$e Release to family r a al/LMAQa Y
ame or vesignatedamdy member to Receive rema emams
❑ 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
_. 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,
T/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
mWner it deems.appropriate.
2. •Mec!zanica#Oii,radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
when placed.iri the cremation 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 of the Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOT Y,,,CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the
remains of the Deceased prior to cremation,and dispose of as indicated:
Mf' Description of I.Vianted Device Disposition
ioro—lImplamnted Device Disposition
owl —"If no tructiert for dispositionis given,such items may be disposed of at the discretion of the Funeral Home.
.,,. The on container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and
irre '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.
144. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings jewelry,and other personal
articles accompan ing the remains of the beceased,may be destroyed during the cremation process.I/We further authorize that if
any items,other<=tlan the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separated
om :ie cret tW remains of the Deceased and disposed of by the Crematory.
15. 144 hereby.40i6rize 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.
wmg, cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverized
to ail;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 cremated remains of the Deceased in a
* container which is not designated for any type of shipment.
.
.:...,fin 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.
--o;. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is