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Travers, Leo 7O r14N OF QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Srm rpC, r Name ff&'g�x Case # Date of Cremation '� ova r Time Cremation Started //Vj r Time Cremation Completed 7l r36i A [t'i � Type of Container 4®©-n 9 Remarks : ,2:-J 41 LAI f J 1,6 A fm � 33 �M , �r l ` i TOWN OF WEEN3HURV PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Uueensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authot^izas Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of! ' (Name) (Sam) 15 (Street ) (City / (State) ( Zip Code) who died on ( day of �""" at �v 1 vim. c w (Place) (Address) of nearest liVing Name and address relatiVe or name Of' , PC Uri authorizing cremationt (Name) (Address) Relationship to the deceased Name of Funeral Home „ IMPORTANT: decitase� ►�' �"' ent that to the best of my knowledge, the ,.� his nocemaker in hie or her body. (Circle One) I certify that 1 have the full power and author the ization to arrang^ for the cremation of the remains andtodirect sionsspo t haveeither personal the cremated remains, that any been removed or may be destroyed, and agree to protect, defen6 and save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them by said ins as reason of or connected with the cremation oorar a e not wholly directed, whether such claims or demands are groundless+ false or fraudulent. I ( itness) (Address) or Legal Rep. and Address) Signature of Relative Signed on this date! I i 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 requested, check 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 persona]. 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 or demands are, or are not wholly directed, whether such claims 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. No styrafoam or plastic containers will be accepted. 5 . The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6 . Unless other arrangements are made the cremated remains will be 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 . G�(4� 031 Rev.4/98 ¢w AUTHORIZATION FOR CREMATION AND DISPOSITION 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 Vwe have the full legal right and authority,an relo now of no ' ing pef wl who�has,a�superior priority right under state law,to authorize the cremation,processing and disposition of the remains of USG ame of Deceased (hereinafter referred to as the"Deceased"). Date one ath Time of Death 1 Is—. , A.M. P.M. I/We hereby request and authorize I — �, (herein r feferred to as the "Funeral Home")to take ameo ome possession of and make arrangements for the cremation of the remains of the Deceased at ameofCrematory (hereinafter referred to as the"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 A No ❑ Deliver to ry Cemetery ame an re o eme Release to family�� 1 �CIO.�TQ%(�S ameo Igoe eaFa em r to eceivZ,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 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 noncombustible casket in any lawful 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 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,it and employees,to remove any such mechanical devices from the remains oithe Deceased prior to cremation, and disp s o items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO ❑ DO N T X NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial 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: 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 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 totally and irreversibly 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. 4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings, ewelry,and other personal articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further authorize that ifl any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separate 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,including 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 pulverize to an unidentifiable 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 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 cremate 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 acknowledge.that even with the exercise of reasonable care and the use of the Crematorv's best efforts.it i� "Customer's Designation of Intentions" Name of Deceased: i r Cremation: '. ' (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: ❑ Burial at Return to Family ❑ Entombment at ❑ Other (specify : I Hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a cop, :of:;`...: this form. -1k (signature) (Printed Name) (Relationship to Deceased) V- dress) ' i f y' 0,11,r— (Telephone Number) $ "Cremated. Remains which shall not have been claimed within 120 days from th"� of cremation may be disposed of by this firm by placement in a columbarium." Printed Naxr4 of Funeral Director Signa Funeral Director Date' oa 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 Malting Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSH-TEN Rev.9J96