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Shevlin, Richard (ro RN OF QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director .` --- IF'7old ` L/ /✓/�- NameliGo�� Case # ZLZ— Date of Cremation Time Cremation Started Time Cremation Completed Type of Container(}!` &C/6 T G'/�j�,�r a Remarks : Ad i TOWN OF UUEEN9HURY pINE VIEW CEMETERY CREMATORIUM Quaker Road, Uueensbury, New York 12804 phone (518) Crematorium 774-44776or IF no answer Cemetery AUTHURItATIUN TO CREMATE in The undersigned ranuoSss and tautooitse,RPin* ules Vand Regulations' to accordance , cr ate the remains of! 'e 2f \ (SON) (Name) (Street F (City) (state) ( Zip Cad ) who died day of 19 at (Place) (Address) , Name and address of nearest liVing relatiV# or name of periori a �i zing creme( ! vn!� lei i� � L) A AA (Name) (Address) ` to the deceased . Relationship � Nape of Funeral Home S, A z 4, . u ,, •_. IMpURTANTs knowled a the do 6asird hat or j l Osent that to the best of my (Circle Une) has o pacemaker in his or her body. arrangeto I certify that I have the full power and dd uthorrecttheti0h t itionof for the cremation of the any personal possessions have either the cremated remains, a and ree to protect, defend been removed or may be destroyed, g 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 Craan�;oareoor saare remains not wholly directed, whether uch claims or de und ies fal p audulent. e /(Hess) (Addre 's) ��pEiIJG � j 1© � y ela ive or e9ail op. and Address) (Signature of ` Signed on this date ! 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_X 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 lose 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. 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 f 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: \ J Cremation: (Scheduled Date) (Location) Manner of Disposition Cremated Remains: I ?i 1 -7- Burial at 11, 1 M Return to Family El Entombment at 0 Other (specify): hereby designate the Disposition of Cremated Remains and aclmowledge receipt of a COPY Of this form. d 7te) vo�-?to Deceased) (-C,1 G", LUd"00) (Telephone Number) "Cremated Remains which shall not have been )aimed within 120 days from the date of cremation mateybe disposed of by this firm by pla !M]e Lt ixf ja c umbarl-11M." Printed Name of Funeral Director Signature of Fkinaral Director Date 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 #9 WHITE;F..rJ H...Copy YELLOW.Family Copy PINK:Crematory Copy CUSH-TMN Rev.4096 4� 4 AUTHORIZATION FOR CREMATION AND DISPOSITION 03lRev.4/9f 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,aVd kCno of o .ving rso h�astta t Re or priority right under state law,to authorize the cremation,processing and disposition of the remains of fC . ,� U N (hereinafter referred to as the"Deceased"). ame o cease /� f Date Death - - Time of Death yCJ ❑ A.M. A, M. I/We hereby request and authorize `' / (herein r referred to as the "Funeral Home")to tak( ame o une ome possession of and make arrangements for the cremation of the remains of th Deceased at (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 k No Describe Description of urn or container selected: Suitable for shipping: ❑ Yes 7,No ❑ Deliver to Cemetery ame ana Address of cemetery ❑ Release to family Name of DesignatedFamily Member to Receive Cremated 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 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 her v authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains oftthe DereO u prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF'1'HE DECEASED DO ❑ DO NOT g 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: Description of Implanted Device Disposition s Descrildon 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 an( 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 fillingsL*ewelry,and other persona: articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further authorize that i! any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separates 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 pulverizes 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 Crematory's best efforts,it i _ _ .. .. • � .L_� __�.. _,._a7..v.... ....... .....d...,..foo4ly hnrnm