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Berkowitz, Darlene TO UN OF QUEENs5BU9Zy PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director-A691hly ot, kNly Name VhK '/V 6 /PJj TZ Case # Z /3 Date of Cremation Time Cremation Started Zz "t /,Jr A/t/► � Time Cremation Completed X rco rjM 1 r Type of Container Cy� ©�T`j(� ��y Remarks : /02 /M/ r%roZ P-11" r TOWN OF UUEENSUURY PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New York 12604 Phone (516) Crematorium 745-447.7 or if no answer Cemetery 745-4476 nu'n 101i I ZAT I ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to mate the r�fi is of : (Name) -� 1^ \� (aert) ls J (Street ) �( City) (State) (Zip Code) who died on I �) day of - ti 2000 at (Place) (Address) Name and address of nearest living relative or name of persun authorizing cremation : LNQ�J't ( m e) --- (Address) Relationship to the deceased 1 � i Name of Funeral Home IMPORTANT: res nt that to the best of my knowledge, the deceasev,..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 dis.pos'ition of the cremated remains, that any personal possessions hay..e.. 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 . (Witness) (Address ) /Y �n2'1!2f- - (Si nature of Ikelativ or LegalRep. and Address) Signed on this date : \ "Customer's Designation of Intentions" Name of Deceas!d: Cremation: V (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: * Burial at ) Return to Family * Entombment at 0 Other (specify): i hereby designate the Dwpoation of Cremated Remains 1 and ac6wwledge receipt of a copy of this form. � V, (Printed Name) (Relationship to Deceased) (Telephone Number) "Cremated Remains which shall not have been claimed witUa 120 days from the date of Cremation may be disposed of by this firm by placement in.a columbarium." Printed NanA of Funeral Director Signatureli&Ftineral 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 Diolmaition) (Location) (Date) Name of Person Making Disposition Signature, Date #9 WHITE:Funeral Home Copy YELLOW.F.Ay'Cftv: PINK Crematory Copy CUSR-TMN Rev.4/96 Gam'!C w 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 CAREFEILLY BEFORE SIGNING. I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority, ow of o living per ho has superior priority right under state law,to authorize the cremation,processing and dispositi of re remains of �+ (hereinafter referred to as the"Deceas " e o eceas �o ate of Death Time of Death ❑ A.M. ❑ P.M. I/We hereby request and authorize n reinafte erred to as the "Funeral Home")to take amen n me n - , possession of and make arrangements for the cremation of the remains o /the 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 rNo Describe Description of urn or container selected: Suitable for shipping: ❑ Yes -❑No ❑ Deliver to Cemetery re eme ry X Release to family an ss Name or Designatedamlly Member to Receive Cremated Remains ❑ Scattering at sea by Funeral tiome 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 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 haza* when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any typ6of-. implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we Ifereby authorize the Funeral Home,its and employees,to remove any such mechanical devices from the remains of the DeceaseAl- prior to cremation, and dispo u items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE ' DECEASED DO ❑ DO N NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initi one Listed below are all implanted ch cal 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. X/ 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 materiaW,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.-- 9. I/We understand and acknowledge.that even with the exercise of reasonable care and the use of the Crematorv's best efforts.it is