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Rich, Stanley 'rO q+N OF QUEEVBUJzy PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director S/ Name /� /� Case # Date of Cremation Time Cremation Startedr `"' �t� Time Cremation Completed `1/'gj4-1 rM Type of Container 4J"_0 26px Remarks : Ad r?-h4 r914, TOWN OF t1UEEN5HURY PINE VIEW CEMETERY R CREMnVURIUM quaker Road, U ueensbury, New York 12804 phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHOR I nT I UN TU CREMATE The undersigned requests and authorize! Pine View Crematorium, in accordance with and subject to its Rules and Regulati'brr+1 to cremate the remains off d� icN /Yip• - (Name) _ (SeN) (Street ) ( ity) (State) Zi t ,p. ' e IL 1 Ooo a day of �{�/�1t,. who died on ,,,_ NOT, at !Address) (Place) Name and address of nearest living relatiVlt =tiro) FJlvt�l+isR7• perttori authorizing cremation! 4 J; , 611 (Name) (Address) c'„ ,;I' Ilk, L.'! 016-o t<im +imiaq lFi;i,d Relationship to the deceased MAP(Name of funeral Nome T-+--�--, � � if .be)q,ms IMPURTANTs k(!a►�. d t+fie, d�ci�as dV as or that my i I represent bodyit h)is orsherf body.. 1 lr_l>�,c;Qfi,oi �3srrce�� has no P a range . that I have the full power,,and;t, 1i!a►;iz# dl$P-Ol it7on of I certify tt�e disp`I for the cremation of the remains ersanaldipaSSAt-s:si ns hake either that any p q• defend the crenated rew+ains' and agree to prote-t, been removed or may be destroyed' g and . a �} ,rl01m and save harmless Pine View Crematorium frowr:;�l+lY aln} ?.o 1ea by es which may be- made ag remains and demaT+ds for loss to damages the cremation of said reason of or connected with ! directed, whether such claims or demands are or are not who) y groundless+ false or fraudulent. (Address) (Witness) 1 r`�`� and Address) (Sig natur¢ of Relative or Legal Rep. Signed on this DISPOSITION OF CREMATED REMAINS I hereby direct Pine view Crematorium to disposes of the cremated remains as follows : Mail to other arrangements - please specify: If pulverization 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 A.M. - 3 : 30 P .M. Monday-Friday. No HoliCays or Sundays, arrangements can be made . for Saturday. Prearrangements by telephone for acceptance of remains is necessary. 2 . Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3 . An authorization for cremation properly signed by the nearest next of kin 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 persona]. 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 rema-ns . 4 . All remains must be encased in a casket or suitable alternate container . Caskets and containers must be of combustible material . No styrafoam or plastic containers will be accepted. 5 . The question relative to cardiac pacemakers must be answered on f the authorization to cremate form before the remains will be accepted. r 6 . Unless other arrangements are made the cremated remains will be mailed via Registered U. S . Mail within three dars of cremation to the funeral home Dandling 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 ) $115 . 00 Inf. its (stillborn to 12 months ) $75 . 00 * Additional $50 . ",0 charge for cremations done after 3 : 00 P.M. Monday through Fr Jay. Cremations done on Saturdays will be h charged the additional $50. 00. f "Customer's Designation of Intentions" Name of Deceased: 7- 6-v I r H Cremation: (Scheduled Date) (Location) Mariner of Disposition of Cremated Remains: E-1 Burial at [3 Return to Family El Entombment at El Other (specify): i hereby designate the Disposition of cremated Remains and acknowledge receipt,-4, of dw form. it bopy (Signature) 1 J AM 15 (Printed Name) (Relationship to''D�"."A'�P�l 04 I L -7­ :4 p _Cljol p, (Telephone Number) fro. "Cremated Remains which shall not have been claimed within 12.0 ;dayof W crem ation may be disposed of by this firm by placement in a-colujjjbariuiA.'i.A.r5 j in 4( Printed Name of Rmeral Director Signature of'Funeral DkT(or 'jWD16' or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED. 15i, Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) ................ ....... ..I Rise of r 6,1..MAiNd vorwitiou Signature Date vrujow Family Coat pum C----.y cow CUSH+TMN Rev.496 �PG,�� �� AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98 IFTHIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNIPTG CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,i arraut and represent that Uwe have the full legal right and authority,and know of no living priority right under state law,to authorize the cremation,processing and disposition of the remains of ! ,PJerson who has a superior (hereinafter referred to as the"Deceased"). ame of IF Dattneiraome th Time of Death f I/We hereby request and authorize_ so") n( i! „JN �� . A.M. ❑ P.M. ame o (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remains of the Deceased at I01n/6 we y f (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 �K No Describe Description of urn or container selected: ❑ Deliver to Suitable for shipping: ❑ Yes ❑No ame an ress o ame cry Cemetery �9 Release to family IV I L V J,IAA ❑ Scattering at sea by Funeral Home or Funeral Home's agent° estgnaMaine ami em r to ecerve remat emams ❑ 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 aml�rlyother ..i 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 material I/we authorize the remains of the Deceased to be removed prior to cremation and placed s, a combustible cremation matecont i al nl I/We further authorize the Funeral Home or Crematory to make disposition of any such noncomWstible 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 hazed. 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 OP`THE DECEASED DO ❑ DO NOT )�CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.J 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' he F'uneraf 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 crematiolf 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 persona'" articles accompanying the remains of the beceased,may be destroyed during the cremation process. Te further authorize that it,o 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 Deceas i*,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 DI�eceased,any excess cremated. remains will be placed in a secondary container and returned to the Funeral Home,together with i11primary urn or container.