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Carter, Grace 1 OF QUEEVBU-�. y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director EE dlq 9L Name y /{ r1e Case # Date of Cremation — 02►� r �,O®Q Time Cremation Started ��l� ��/� Time Cremation Completed gr .3 a- A Type of Container_��1L�/�.�u/T/L� Remarks : �t TOWN OF UUEENSUU11Y PINE VIEW CEMETERY jjjJJJ C11EMA'fOR I UM Quaker Road, Queensbury, New York 12604 Phone (516) Crematorium 745-447'7 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 : (Name) (Sen) _f (Street ) (City) (State,) (p .Code) J who died on �� i day of 1-LQ2C1 2` � x at C L C N<S (Place) (Address) Name and address of nearest living relat.iv,e „or name of person authorizing cremation : iiDihw _Aacc' C,A� C>l2 v'ons,�7.� (Name) (Address) Relationship to the deceased Name of Funeral Home �2vrCK >L/tl IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. .(C.ircle ph!9r�trG�;ir;'1.� d I certify that I have the full power and .aut;h�axritAtIMVs&o arrange for the cremation of the remains and to direct. the disposition of the cremated remains, that any personal pbssessi6n5 '-h.*. e 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 ) (Signature of Relative or Legal Rep. and Address) � C�) Signed on this dates,-� ��T p RE' AN & DENNY FUNERA,,�!i,, ICE 9tux,-11sbury, New 2%!-'f. "Customer's Designation of Intentions" Name of Deceased: Cremation: (SA.".a Date) (Location) Manner of Disposition of Cremated Remains: 0 Burial at 9 Return to Family El Entombment at El Other (specify): I hereby designate the Disposition of Cremated Remains and acitnowledge receipt of a copy of this form. (Prints&Name) (Relationship t.D--mea)t (Telephone Number) "Cremated Remains which shall not have been claimed within 120 Jays from the date of cremation may be disposed of by, this firm by placement in a columbarium." k,(,) Ajo F-1--I 11 Printed Name of Funeral Director Igipatu"of Funeral D��- Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMAIT.P,R.E MA�N Crematiow. (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (M—of Disposition) (Location) (Date) Name of Hwwn Making Disposition Signature Date #9 WHITE:Funeml Home Copy YELLOW Family Cow PINK:Crematory Copy CUSUMN Rev.4M �o°,�� AUTHORIZATION FOR CREMATION AND DISPOSITION . THIS ISA LEGAL DOCUMENT IT CONTAS IMPORTANT PROVISIONS CONCER 031Rev.4N8 CREMATION IS IRREVERSIBLE AND FINAL.READ NING CREMATION. Ts DOCUMENT CAREFULLY BEFORE SIGNING. UWe,the undersigned,certify, rVresent that Uwe have the full 1 Priority right under state law,to. �right and authority,and know of no living the cremation,Processing and disposition of the remains of g person who has a�perior (hereinafter referred to as the"DeceasWI). r cle -_ _�yG me a e 1E PO Date of Death /7 Time of Death e hereby request and authorize '{' jh(K •�, y X A.M. ❑P.M. Possession of and make arrangements (hereinafter referred to as the "Funeral Home's to _ ements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"), 01 1-4L �1 f I/We hereby authorize (— ame rcmatory a} the•Crematory to return the cremated remains of the deceased to the possession and custody of the Fun I/We understand that the services and obligations of the Cremat shall be possession and cust m'Y fulfilled when the cremated remains of the deceased are Deceased as follows: auth°rtze`the.J» •a(.Home to arrange for the disposition of the Hha°dlingreluired? ❑Yes [X No Describe DesCIipdoa of urn or container selected: ❑ Deliver to Suitable for f Release to family, Lr RAN s ❑ Staffs • .-:x: 3� ._ _ .:. ring at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S.Registered Mail* tl , 1b:Name ❑ Other Address ' neral Home and Crematory are not y responsible or an less or l Service. damage cremated remains shipped via R . Posta The cremation,processing and disposition of the remains of the Deceased authorized herein sh t 1. all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and � • nce with: 1. The remains of the Deceased will not be accepted for cremation unless received by the r 3 atld eondltions: -. resistant,rigid cremation container.The Crematory-is authorized to remove and dispose. noncombustible items attached to the cremation container prior to cremation. In thee` combustible, leak- eats received by the Crematory in a casket or other container constructed of metal,fiberg and any other Uwe authorize the remains of the Deceased to be removed,prior to cremation and pia the Deceased are . I/We further authorize the Funeral Home or Crematory to make disposition of any testable materials, manner it deems appropriate. tion container. . !� met in any lawful f when placed in the cremation cham er..The•Cr atory�wl no cremh ed such implanted mechanical or radioactive device. In the event the remains of the erealRarrazard authorize the Funeral Home,its agents and employees,to r t the �em�y such m d 'tice, Ilwe hereby prior to cremation, and dispose of such items at its discretion. UWE HER of the Decea DECEASED DO ❑ DO NOT ACONTAIN ANY TYPE OF IMPLANTED x REMAINS OF Tar Please initial one. DIOACTIVTpEV E. Listed below are all implanted mechanical and radioactive devices which the remains of the Deceased prior to cremation,and dispose of as indicated; " ,p ized to remov the ,, Description otImplaated Device ='"``_ Descripflon of Implmted Devlee y- If no instruction for disposition is given,such items ma Drjoo p Y be disposed of at the dis T `�' some. -`:�"` 3. The cremation container coatainin the remains of the Deceased will be placed irreversiblydestroyed b prolonged tp 1-'and will be to,-.,ally and Y Y a gedess and r to intense heat and direct tlatne,.I y to open th mation chamber during the cremation process and reposition the remains of the Deceit ~ fete a cremation. omp orough 4. Certain items,including'but not limited to body prostheses,dentures,dental b articles accompanymg the remains of the beceased,may be destroyed during tilt 4 Iry,and otei•per+�nal any items,_-other than the cremated remains of the D are recovered f1� further authoe t�rat if from the c#emated°remain3-of th#Deeeasbd and di of by the�re<ehto may be separat;d 5• I/We herebt:aathorize the Crematory to separate and remove from the cremation ` but not Iinuted to,hinges,latches,nails,jewelry and precious ematerials ' uding, i. Followmig cremation,the cremated remains of the Deceased, ,to an um entifutble consistency prior to placement in rn or Otheg co rdyof _i y pulverized '• Unless an urn or container suitable for shipment is purchased,the Crematory will container which is not designated for any type of shipment. cK iz °of the Deceased in a p 1w` r.�. In the.event.the urn or container is insufficient to accommodate all of the cremated remaia_ e� y remains will be placed in a secondary container and returned to t1ap 1Hlsna—i u..,.,o .�. . excess cremated, iIZATION FOR CR -MATION AND DISPOSITION 031Rev.4/98 P� • -OR u,m ENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ` C JfffioN IS IRkEVERSIBLE-AND FINAL.READ THIS DOCUMENT CAREFULLY BEFO t I/We,the un ed,certify;w4} Kand represent that Uwe have the f d legal right and authority,and know of no living person who has a superior authorize the cremation,processing and dilion of the remains of (23 I��G L prio ' under state lavr �Name of Deceased after referred a" " Date of d pp Time of Death Jul c�� [$'_A.M. ❑ I/We hereby req69t and au*orize' (hereinafter referred to as the "Funeral Home"/ possession of and a arrangeinen the cremation ains of Deceased at -: ame o Crematory (liereinafr reheard to as the"Crltatory"). a •• ;-� + "I/We hereby authorize the Crematery to r the crejj ted rem�tinB of the deceased to the possession and custody of �td ons of the Crematorgl be fulfilled when the cremated remains of-the I/We understand tliate servi .deeea ' ®tly of tbe:�aneral Home.I/We hereby at prize the Funeral-Home to arrange for the isposition of the cre1N_ # e Dee�as follows: - .. Is special handMig required? .❑/Yes [A No Descri t Description ofurnmon9wr selected: _ Suitable for f ` x Cemetery WPPM GI Release to file iily f '- ame am ve ❑ Bering at seat Home _.or FunTf4�a ? To:Naoia - ". d M ❑ Other ! -a- .•. = T re rye - t responsible forts loss or d a red via R States .A Postal Service. ` The cremation;process' . d;dlTositi6firofthe remains of t beceased''authorizedherern _accordance wit' all governisigbtws,the s,r and policies of the Cli4matory and Funera!Home; sand condition 1. The remains of the Deeaoed wi 1 ted.for cremation unless received by tlie?' f t In 4 combustible, leak resistant,rigid cremation contained he' ry is all to remove and di rnaments and any other noncombustible items nttached�o the crematio in prate cremoti_ I: sins of the Deceased art -received by the Crematory i ashet or other con c ucted of=met-1,, 1b stible max�la _ Uwe the ecea�t be remo for to cremation and a6iopn con I/We further authort a uneral Home©r�rem-. to makeFjwsition tlf manner itdeems aFPr4Priate. 2. Mechanical or radioactive devices i _ nted.in t ins of tl 1eceased(. c.) may create a haz when placed in'the cremation r. TlW pry will not cremate an 6 i . contain any ty d im--7anted mechanical or " O ctive device. In the event the remains of the "u evice I/we bJ authorize the Funeral home;Its agents and employees;-to remove any_such fnechaa a rem of ease4 prior to cremation,ar�d dispose of such items,at its discretion. UWEIM SHE RE [AI S-OF TH DECEASED DO ❑ DO NOT X CONTAIN ANY TYPE OF IMPLANTS DIOACTIV14DEVIC� - x Please initial one. �Y Listed below are all implanted mechaoical and radioactive devices which the Fu � thorized to remove om th remains of the Deceased prior to cremation,and dispose of as indicated: Description of implanted Device - Disposition Description of Implanted Device Disposition `} If no instruction for disposition is given,such items may be disposed of at the diseret' ;4ome: ` , 3. The cremation container containing the remains of'tie Y'eceaseil will be pine �t to ?! wt e t irreversibly destroyed by prolonged exposure to intense.1feat and direct flame. o n the cre tin chamber during the cremation process and reposition Ae remains of the Ty - c6gtplete and thoroul cremation. = , 4. -Certain items,including but not fimited4o body prostheses,dentures,dental , o, �persoq articles accompanyingand the remains of the beceased,may be destroyed durin " at d of a that any items,other than the cremated remains of the Deceased,are recovereY rat from-the cremated remains of th$Dedea"d And 4ispgtte&ofby`th0Cr 5. I/We hereby authorize the Crematory to separate and remove from the creme materials,inclu i but not limited to,hinges,latches,nails,jewelry and precious metals,and W. 6. Following cremation,the cremated remains of the ceeaspd,consisting primair y" IN 5,10be mechanically pulverii to an unidentifiable consistency prior to placement in an urn or other container}t 7. Unless an urn or container suitable for shipment is purchased,the Crematorye 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 cremate aan~excess remains will be placed in a secondary container and returned to the Funeral Home;to or conk` e`' hest effort irxx7,......i....��..,..i—A'..>t,,..��paeP that Pvpn with the exercise of reasonable care and t � � .e !`�_w= �