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Kirschen, Daniel L O OF QUEEVBURYPINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director "4 Name A(,g A Case # Date of Cremation �� — Time Cremation Started /e/' 5-4 rM f r Time Cremation Completed l�r / )VIM J Type of ContainerG'/M�,e��/ czYP/ C195T- ©)f'��/�t-�� Remarks : _�� %4 TOWN OF QUEENSDURY PINE VIEW CEMETERY CREMnTOts I UM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 nuniriR 1 znT nu ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the ire/mains uf : (Name) �I Ln,.n��, ti9Ur IUnr �� P,,-� ri. 3y-? (Street ) (City) (State) (Zip Code) who died on 45 ' day of YY7r2 c27 2000 at / -)(ls' L)ri JacrL rido. (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : .-rxm(�s ar',) 2H 2,� (3 ur"rAn 1t (Name) (Address) Relationship to the deceased �or �lic. Name of Funeral Home IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (C.ircle One) I certify that I have the full power and •aut:horization 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 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 . (Wit s) (Address) gnature of Re ative or Legal Rep. and Address) Signed on this date : „'31/7 RE & V Fjj 'iF "Customer's Designation of Intentions" Name of Deceased: Cremation: C, "(Scheduled Date) (Location) Manner of Disposition of Cremated Remains: El Burial at xReturn to Family 0 Entombment at 0 Other (specify): I hereby clesignate the Disposition of Cmnated Remains andaCknowledge receipt of a copy of this form. (Sign tam (Printed Name) C7 (Relationship to Deceased) 3� 11 Vidd-00) S/.r- 7 9- (Telephone N-..]—) "Cremated Remains which shall not have been Claimed within 120 days from the date of cremation may he disposed of by this firm by placement in a columbarium. Printed Name of Funeral Director Signature dfr-nneral Director Date" or Under"" 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 VTIM:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSRMN Rev.4/96 AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98 E:!!NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. C!REMATION 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 living 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 ora n 1,as P_l k i r s 1 ece - Date of Death 3 /.S-jOD Time of Death J A.M. ❑ P.M. I/We hereby request and authorize vt o an -�j� 1� -"Name'of e n e c ` " (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remains of the Deceased at f 3 (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 ANo Describe Description of urn or container selected: Suitable for shipping:m • ❑ Yes E No ❑ Deliver to ame an ress o em ry Cemetery El Release to family ame of DesignatedampMe m r to ecerve remat emams Scattering at sea by Funeral Home or Funeral Home's agent 11 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,rig 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, a ch items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO ❑ DO NOT C NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please 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 persona articles accompanying the remains of the eceased,may be destroyed during the cremation process. a further authorize that' any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separat 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,incluc"nt g,-" 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 pu "zed 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 Dece. d in a container which is not designated for any type of shipment. -14 "Customer's Designation of Intentions" Name of Deceased: Cremation: 31 1;1) j 0 o (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: El Burial at XReturn to Family El Entombment at 11 Other (specify): I hereby designate the Disposition of Cremated Remains.and acknowledge receipt of a copy of this form. (Signatuf cl Y), C,N (Printed Nam.) Gr (Relationship to Deceased) (Address) -S)X- 7 9. (Telephone Number) "Cremated Remains which shall not have been claimed within 120 clays from the date of cremation may be disposed of by this firm by placement in a columbarium." 0')0 1 Printed Name of Funeral Director Signature dft-uneral Director 'Date" or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSMON 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 WHrM:Funeral Home Copy YELLOW.Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96