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Rabideau, Donna 70WN OF QUEEVBUr y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director r6—' ' N Name /�/�� ,�L a Case # Date of Cremation —/ — actno Time Cremation Started �6 t'�tc A 1 M t Time Cremation Completed -et.36-7- AIM , Type of Container �� A� �SrC �,��© Remarks : r /, �/✓� r IL4 r r/© iA4 TOWN OF QUEENSDURY PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New York 12604 Phone (518) Crematorium 745-4477 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) (Se><> � (Street ) (City) (S ate) , (Zi,p-,Code) who died on 'o2(n t day of lrL'�13fZ11 Ste`' at 1��. 1;1\LS l=�L —f,�oS�J a 1, : r •. , ,. : .. ;e f (Place) (Address ) Name and address of nearest living rel;at,i �!e:: L,r;•y „�na�rnze�, of person authorizing cremation : (Name) (Address) P Relationship to the deceased Name of Funeral Home /2-li AAA( IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body: "�lq t I certify that I have the full power' a'nd'{'.auttibo izat`-i'6ns(to arrange for the cremation of the remains and to direct.,the disposition of the crenated remains, that any personal`" 'I either' ' either l al been removed or may be destroyed, and agrve '' 't'o`•'p�'o't�f defend and save harmless Pine View Crematorium from any,•andf . al claims and demands for loss or damages which may 'be M.&d4-`-'a9,a1nst Athem by reason of or connected with the cremat:•io.ri 0"f5'a`i�lt--mains as directed, whether such ims or demands are or are not wholly groundless, false or f audu ent. ( fitness ) (Address ) (Signature of elative or Legal Rep. and Address) igned on this date : 031 Rev.4/98 o ¢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 Uwe have the full legal right and authority,and knop of no living person who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of Name 0�Kcal �iR t L�/°�A J eased (hereinafter referred to as the"Deceased"). a�� ❑ Date of Death o�� d Time of Death (o;d.`S A.M. N P.M. I/We herebyuest and authorize , mat nom (hereinafter referred to as the "Funeral Home")to take re 1 Name o uner o possession of and make arrangements for the cremation of the remains of the Deceased at � V4 Crematory (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 I No Describe Description of urn or container selected: Suitable for shipping: ❑ Yes No A,�^ Cemetery Deliver to , ;AQA Lo n �� ��l��A ame an resso eme ry ❑ Release to family ame o ignated Family 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 I 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 Decease prior to cremation, and dispose of such items at its discretion. I/WE HEREBY,CERTIFY THAT THE REMAINS OF THE, DECEASED DO ❑ DO NOT XI 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 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 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 to g irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the crematic chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorou� cremation. 4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings jewelry,and other person articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We further authorize that any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,er,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 ma.Lripls,includii 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 mech:;:;,. I►;pulveriz 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 it 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 cremal remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or containe' ., rAn____a _ . . , ....,, . I,,.,...,Io,L,o th.t—an with the PYPrvicP of reacnnahle care and the use of the Crematory's best efforts,il "Customer's Designation of Intentions" Name of Deceased: Cremation: (Scheduled Date) (Location) '.r Manner of Disposition of Cremated Remains: e Q Burialat El Return to Family �, X Entombment at A J!/) lCG,�q j7i,9�'! !u'"f�. ❑ Other (specify): 41 �w � •r pp � I hereby designate the Dis 'tio of Cremated Re dins a8mowledge. . .,�s of this form. , R 9(sigature) (P�inted Name) (Relation+h p.- seed) (Telephone Numher) ' "Cremated. Remains which shall not have been claimed wi �,ye from ihe`'daie of . cremation may be disposed of by this firm by placement in ar /el I_i r`� � I �.��'..�• . 7 J /r '.J�(_' _/ ��-i +tom' , Si Printed Name of Funeral Director �ature of Funeral or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF'~, MA n S ` ` Cremation: .�., (Actual Date) (Location. Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) +, Name of Person Making Disposition Signature #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy