Toomey, Barbara rf-O WN OF QUEEVBU-RY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,/ ,G,
Namej oe
Case #
Date of Cremation ,i—
Time Cremation Started
Time Cremation Completed
Type of
Remarks :
,/ Act/ ilY1
TOWN OF UUEEN98URY
MINE VIEW CEMETERY
1R
CREMAtORIUM
Quaker Roadt Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or 1F no answer
Cemetery 745-4476
AUTHURIZATIUN TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains offer �Ql
(Name) (Sex)
11
zlkjla--�r
(Street ) ,,/�j� (City) (state)` / ( Zip Code)
who died on /'5 ) , day of
at Le)
( lac (Address)
Name and address of nearest livin relative or name of perturi
authorizing cremationtip��
(Name) (Address) n
Relationship to the deceased
Name of Funeral Home /Al �1��^
IMPURTANTf
I re resent that to the best of my knowledge, the dOcirasird ,hal� ;or ,
a A
as n pacemaker in his or her body. (Circle One) ,
I certify that I have the full power and autnorizatio to a. .,-tinge
for the cremation of the remains and to direct the dispostt'.on i
that any personal possessions have either
the cremated remains,
been removed or may be destroyed, and agree to protect, defer"
and save harmless Pine View Crematorium from any and all
and demands for loss or damages which may be made against them 3Y
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are o are not wholl*.
g undlesst fait or ral ulent.
Witne s) P (Address) �
(Signature of Re ative or Legal Rep.f�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:
If pulverization of cremate remains is requeste , chec 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
which may 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 .
' � . styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
authorization to cremate form before the remains will be
accepted.
_ zless other arrangements are made the cremated remains will be
D' 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: 'T'
(Scheduled Date) (Location
Manner of Disposition of Cremated Remains:
C] Burial at ( � I�A R ❑ Return to Family
❑ Entombment at ❑ Other (specify :
. .ti
I hereby designate the Disposition of Cremated.Remains and ac6owledge receipt of a copy of
this form. ' t
rL
( ame) � (Re do 'lo- eceas
A, A)r- --V�kj\
.�--• i •, '�`aA t}[I[I;�}gyp �"—
(Telephone Number)
rtrtq'z 11.A V
"Cremated. Remains which shall not have been Claimed. within- :.320 day, sf u- Itb®.., f
cremation may be disposed of by this lirm by p cement in pt co�timibar
4
Printed Name of Funeral'Director Signature of Funeral Director D'
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAIN -
Cremation:-
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
1
#9 WHITE:Funeral Home Copy YEUd OW.Family Copy PINK:Crematory Copy CUSU-TEN Rev.4/96
�oow�w AUTHORIZATION FOR CREMATION AND DISPOSITION 03I Rev.4/98
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 agd represent that Uwe have the full legal right and authority, now f no liven rson o has a su er'or
priority right under state law,to authorize the cremation,processing and disposition of the remains of Ri�9R , �/'1?
(hereinafter referred to as the`Deceased"). _ ame n —,
Date of th t7�-*ime of Death
I/We hereby request and authorize
S° 0 /�� A.M. ❑ P.M.
am .10
e o uoera ame (hereinafter referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remains of th eceased at
(hereinafter referred to as the"Crematory")• Name of 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 K No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to
ame an rasa o ame ry❑ Release to family Cemetery
am a Family Member o ecerve—1-ated 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 dis
noncombustible items attached to the cremation container prior to cremation.In t pose of handles,ornaments and any other
he 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 taw
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a razrd
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any .ypeo + "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.QF THE
DECEASED DO ❑ DO NOT g CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DE`'.ICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remo,
remains of the Deceased prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
F� r
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.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be 07
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cre'
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete a
cremation.
4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings,�'ewelry,ant!othP
articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further a`
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may b�
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 material
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
6. Followingg cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverized
to an unidentiflable 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. i
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 primary urn or container.
9. I/We understand and acknowledee.that even with the exercise of reasonable care and the nse of the CrPrnatnrvIc hPct nffnrte it ic