Cavanaugh, Esther rr0l+N OF QUEEVBU-Ry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '/ M
Name 16i 7"ff�/'t C� �( Case #
Date of Cremation "
Time Cremation Started 75t%3si9/M r
r
Time Cremation Completed to A'M r
Type of Container
Remarks :
TOWN OF t]UEENJgUftY
PINE VIEW CEMETERY
CREMAtURIUM
Uualcer Road+ Uueensbury+ New York 12904
Phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHURUMIUN TU CREMATE
The undersigned requests and authorize! Pine View Crematorium+ in
accordance with and subject to its Rules and Regulations to
cremate thw remains of! '
(Name)
(sF) ��
(Street ) (City) (State ( Z�p Code )
who died on 5— day of
a t _ G
(Place)
t11.111ddress)
Name and address of nearest IlVing rel0t1V* or name of pergo►i
authorizing cremation!
(Name) (Address!
Relationsrtip to the deceased
Name of Funeral Nome
IMPORTANT! knowled the dectosed haft or
I re resent that to the best of my g +
as no acemaker in his or her body. (Circle Une)
the full power and au':horizatioh to arrange
I certify that 1 haverect the
for the cremation of the remains ersonaldipossessionsshaveteither
the cremated remains, that any pd and a ree to protect+ defend
been re�e�ved or may be destroy + g
and save siarmless Pine View Crematorium from any andiinstl then iby
and demands for loss or damages whichCte may be made against
d with e cremation o said
reason of whether+,s UCH clais or demandsnreorart notain wholly
directed,
groundless# alse or fraudulemnt.
8G
( fitness) (Addres-s)
(Signature of Relative o gal Rep. and. Address)
9igned on this dates
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to 1�d
other arrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 . The cremator sum will be open for creNaoti�;olidaysyseek or wSundays�
A.M. - 3 : 30 P .M. Monday-Friday. Pre arrangements by
arrangements can be made , for Saturday. *
telephone for acceptance of remains is necessary.
2 . Pine View Crematorium i located on the Town of Queensbury rounds of the Pine
View Cemetery, Quaker Road,
3 . An authorization for cremation properly signed by the nearest
next of kite 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
will be accepted.combustible material .
No styrafoam or plastic containers
5 . The question To relative cremate o
to cardiac
form p before the
ers must
r remains answered wil on
be
the authorize
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
I 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: 1/
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 copy of
this form.
(Signature)
i f"
(Printed Name) (Relationship to Deceased)
(Address)
r !r
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
! '
Printed Name of Funeral Director Signature of Funeral 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 Malting Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSMEN Rev.4196 ;
PC�`ti�
0
�w4� AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98
E:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
NOTIC
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 ow,qf no livi person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"). _ anie or Deceased
Date of Death Time of Death J, 30 —A.M. P M.
I/We hereby request and authorize — (hereinafter referred to as the "Funeral Home")to take
m ae o unera ome
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). Name o 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 X No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Cemetery
ame an ress o eme ry
❑ Release to family
Name of Designatedamp em to Receive Ummated 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 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 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
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.I/ a further authorize that if
any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separated
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 pulveri --
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 Decease
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 cr ted
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or cont r___
n TAXT .._a _ a�_a _a , a,_..__,l, j— aa.,.a _, .__,:aa ai .. _ —4P—...--- t.t ..a a� rat. ! .. a .a t a,.ru as.
/Ieol�llr
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 livin person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"). ame o ece
Date of Death ��/;f�0 Time of Death / 2.30 ❑ A.M. XRM.
I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to take
ame o uner Home _
possession of and make arrangements for the cremation of the remains of the Deceased atJ
(hereinafter referred to as the"Crematory"). ante o remamry
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: a Yes LEI No
❑ Deliver to Cemetery
O ame an Address o Cemetery
�C! Release to family. ,Q 4.g As
Name of Designated Family Member to ReceiveCrematedf 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 hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains oFthe Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO -7 DO NOT &-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
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 filli is,Awelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further authorize that if
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be separated
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,includin
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 pulver'
to an un entiflable 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 Deceas I -
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 cr ed
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or con r.
A i/�S]_ __�J_�_a__J ��J ,_._L_..__.l..J.�.. ♦l...L..�...�....:41.♦1.....v.......o....F..,,nn.....,hlu nn.o nr..I 4he..on.,f rho!"ro.,,o*..�.,�� hncf nffn if is
�oow4w 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 no of no I' ing person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"), ame oDeceawd
Date of Death0 Time of Death f 2 ❑ A.M. <P.M.
I/We hereby request and authorize 2 ,tom (hereinafter referred to as the "Funeral Home")to take
NameofFunera Ho
me
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"), ame o 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 P(No Describe
Description of urn or container selected: Suitable for shipping: Yes =i No
❑ Deliver to Cemetery
ame an Address o cemetery
❑ Release to family
Name of DesignatedFamily Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
El 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,its agents and employees,to remove an such mechanical devices from.the remains oithe Deceased
prior to cremation, and dispose ofuch items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOTCONTAIN 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
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,jewelry,and other personal
articles accompanying the remains of the eceased,may be destroyed during the cremation process. a further authorize that if
any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separated
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,includin
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 pulver'
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 Deceas
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 c ted
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or co er.
—A Oho....of♦ o('rnm�4nrv�e tenet nff h vm h :*:e
w
Name of Cemetery/Funeral Home
RECEIPT OF CREMATED REMAINS AND RELEASE OF LIABILITY
The undersigned hereby certify that they have the legal right to tape custody and mare disposition of the cremated remains of
the deceased, and hereby acknowledge receipt of the cremated remains of:
NAME OF DECEDENT:
The undersigned further assumes full responsibility for the lawful and proper disposition of said cremated remains.
The undersigned hereby agree to indemnify and hold harmless the above named cemetery/funeral home, its agents and
employees from any and all liability, including reasonable attorney fees, and against any loss it or any of them may sustain in
connection with the receipt of, shipment of, or disposition of said cremated remains.
Further, the above named cemetery/funeral home shall be held harmless from any defects or faults of any container not
supplied by the cemetery/funeral home.
Date this day of , 19
Address
Street City State Zip
Signature:
Authorized Representative SSN # Photo ID Relationship to Deceased
Signature:
Authorized Representative SSN # Photo ID Relationship to Deceased
Witness:
Representative of Cemetery/Funeral Home
WHITE: Funeral Home Copy YELLOW: Family Copy FORM C04 REV. 12/91
#8 i
.'l
b�ne oT 1�emAery/Funeral Home
RECEIPT OF CREMATED REMAINS AND RELEASE OF LIABILITY
The undersigned greby certify that they have the legal right to take custody and make disposition of the cremated remains of
the deceased, and hereby acknowledge receipt of the cremated remains of:
NAME OF DECEDENT:
The undersigned further assumes full responsibility for the lawful and proper disposition of said cremated remains.
The undersigned hereby agree to indemnify and hold harmless the above named cemetery/funeral home, its agents and
employees from any and all liability, including reasonable attorney fees, and against any loss it or any of them may sustain in
connection with the receipt of, shipment of, or disposition of said cremated remains.
Further, the above named cemetery/funeral home shall he held harmless from any defects or faults of any container not
supplied by the cemetery/funeral home.
Date this day of 19
Address
Street City State Zip
Signature:
Authorized Representative SSN # Photo ID Relationship to Deceased
Signature:
Authorized Representative SSN # Photo ID Relationship to Deceased
Witness:
Representative of Cemetery/Funeral Home
WHITE: Funeral Home Copy YELLOW: Family Copy FORM C04 REV. 12/91
#a