Nusskern, Ruth 70 WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S I M /
Name P- Case # J 67
Date of Cremation �'o
Time Cremation Started CGS
Time Cremation Completed
Type of Container e A Rs 0CL r-.L- PAY
Remarks : /i
DTI o Z6124
P, m,
TOWN OF WEENSHURY
PINE VIEW CEMETERY
A
C"EMAtURIUM
Quaker Road, Uueensburyr New York 12804
Phone (318) Crematorium 745-4477 or of no answer
Cemetery 745-4476
AUTHURIMMN TU CREMATE
The undersigned requests and autho(^iza! pine View Crematoriums in
accordance with and subject to its Rules and Regulations to
cremate the remains oft '
u7% MVIS :,—=,PA)
(Name) (Se►e)
31 M.�u.✓� :.✓ Vi�ry .CN Q�sEEtis6N e
(Street ) (City) (State) ( Zip Cod
� day o f .QoQ;I }�-atDoO
who ^died on
at l9'/6N A l/S
(Place) (Address)
Name and address of nearest living relatiVO or name of , per%or'
authorizing crematlont
/ mD u.✓tea,J�/ 1/� w 1.-+� C�eI F E.v c u e
Gusf�✓ A/�sst�R•✓ (Address)
2--
(Name) dress)
Relationship to the deceased
Name of Funeral Homes // i�+�✓ M` 'V r4-A '-n? tER
IMPURTANts knowledge, the deceased ha• or
I re resent that to the best of my (Circle Une)
Chas n ' pacemaker in his or her body.
I have the full power and aut'torizMtiOh to arrange
I certify thatrect
for the cremation of the remains ersonald todipossessionsshaveteither
the cremated remains, that any p agree to protectr defend
and a
been removed or may be destroyed, g
and save harmless Mine View Crematorium fro* any and all claims
and demands for Loss or damages which may be made against them by
ins 89
reason whetherr�suchd with claims orthe
demandsoareoor. are notawholly
directed,
groundlessi false or fraudulent.
o-7 �tbtidz
(W (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this dater �dGO
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 pi-.lverization 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
- 3 : 30 P .M. Monday-Friday. No Holidays or Sundays,
A.M.
arrangements can be madeof remainsturda is necessarye*rrangements by
telephone for acceptance
2 . Pine View Crematorium is located
wn Of dueensbury grounds of the Pine
View Cemetery, Quaker Road,
3 . An authorization for cretgation properly signed by the nearest
next of kite or w-her 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 retrains must be encased in a casket or suitable alternate
container . Caskets and containers must be be acc pte of combustible material.
No styrafoatn or plastic co
5 . The question � o cremate form before the
relative cr to cardiac pacemakers
must
remains answered wil be
on
the authorization
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 ) $1151 . 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:
Cremation:
(scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at P Return to Family
El Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
r- I,,- f,-,
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone N—.J-,)
"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 Sign#(ure,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 Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family C." PINK:Crematory Copy CUSMEN Rev.4/96
PCG`Z'�C
AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/91
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 living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of Au fh w /y u rs k,0 fZ N .
(hereinafter referred to as the °Deceased"), ame o
Date of Death A2,'R r J,appp Time of Death ®S X A.M. ❑ EM,
I/We hereby request and authorize9cf/t it/*',—M f tg P (hereinafter referred to as the "Funeral Home")to takf
ame o Funerm "me
possession of and make arrangements for the cremation of the remains of the Deceased at RME
(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? XYes ❑ No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to
ame an ress o eme ry Cemetery
Release to family �S f-AiJ Ill G c t fZ F tPn/
Name o Designated Fame em r to Receive ,remate�emains
❑ 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 oithe 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 ;;kONTAIN 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 ant
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 beceased,may be destroyed during the cremation process.'I/We 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 pulverized
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 a
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 cremated
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
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