Kazazean, Azad zo WN OF QUEEMB U-0�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director _- / To q
Name Azh D Case # o� /
Date of Cremation ':;Zc�
Time Cremation Started ZrAle 1/. f
Time Cremation Completed It tM�
Type of Container J16142
Remarks :
'v 3 eyl-m r
TOWN OF UUEEN"UnY 04-1
PINE VIEW CEMETERY
A
CREMAtOnIUM
uuaker Roadt uueensbury, New York 12804
phone (518) Crematorium 775-44476or if no answer
Cemetery
AUTHORIZATION TO CREMATE in
The undersigned raQ�eSscauos, p View
and Regulaticnsr to
accordance with
ub,jet to its Rles ,
MaL2
mai s oft
(SOM)
(Name)
(City State) ( Zip Code)
(Street )
day of �
who died anat S
(Place) (Address) bn.b
Na
me and address of nearest livin YelatiVe or name of1,--Jotrtoti
authorizing cremation!
(Addy s s) r!tq
(Name)
iSr
Relationship to the deceased .; a a
Name of Funeral Nome
1MPOnTANt: knowledge, th4t dtcir+a��d 's or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body. . v
I certify
that I have the full power and authoritAtloh to' dtrange
' �,o n o
ion of the remains possessions hav
for the cremation and to direct the d sFo";
that any personal possese c_9
ith.:r
the crenated remains, ed d agree to prof °c' tl4fend
been removed or may be View Crematorium froa any and destroy r an S r;.;lair^s
and save harmless Pine �s,F.
and demands for Ions or damages which may be made again then by
reason of or connected with the cremation of said -en�sins as
directed, whether such claims or demands are or are not wholly.
a se or fraudulent.
i
grou le s
,. Witneg )
(Address)
al Re and. Address)
(Sign tut-0 of Relative or Leg p•
Signed on this dater
DISPOSITION OF CREMATED REMAINS
I hereby direct Pii-,e View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrange►nerits - please specify:
If pulverization of cremate remains i requested,equested, 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 Holidays 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
Cre:rmatorium from any and all claims and demands for loss of damages
whie)i may be made against them by reason of or connected with the
crelvation.. of said remains and/or disposition of said remains as
directed, whether such claims or demands are, or are not wholly
groundl'bss, false or fraudulent . This authorization in addition to
a regular burial permit must accompany the remains .
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
the authorization to cremate form before the remains will be
•cepted.
Unless other arrangements are made the cremated remains will be
.na ,led via Registered U. S . Mail within three days of cremation to
the funeral- home _'handling the service . There will be a $20 . 00
4 charge for ,this service.
Cremation, Administration Costs and Recording Fee: Adult $195 . 00
Children (age 13 months to 12 years ) $115 . 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 .
PGr4C
'0�w4� - AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98
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,certifS warrant and represent that Uwe have the full legal right and authority,and ow of o li erson who has a superior
priority right under state law,to authorize the cremation,processing and disposi on of the remains of 7 6 2,-m—
(hereinafter referred to as the"Deceased"). ame ecease �p
Date tath Time of Death A.M. ❑ P.M.
I/We hereby request and authorize — (he ein er referred to as the "Funeral Home")to take
ame o opera o e
T ,
possession of and make arrangements for the cre6ation of the remains of th ased at
(hereinafter referred to as the"Crematory"). VName 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! Yet"
No Describe
Description of urn or container selected: 11 Suitable for shipping: es ❑No
El Deliver to Cemetery
ame an ress o em ry
elease to family l C L C kQ
Name ot Designated FainqMember 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,rig
id 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 cre r.
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, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DO NOKWNTAIN 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 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 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 Fm*erel-Nome,together with the primary urn or_container_
9. I/We understand and acknowledee,that even with the exercise of reasonable care and the use of the Crematorv's hest --
QG'�4't
031Rev.4/98 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,an now of n livi erson who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of H zaa�C{Z Q.Mqn
(hereinafter referred to as the"Deceased"). cc
Date Death\J I k (h7 Time of Death � � ^ g 7 A.M. ❑ P.M.
1:7I/We hereby request and authorize ` (herein 'referred to as the "Funeral Home")to take
ame o Funeralome
possession of and make arrangements for the c ation of the remains oft ceased 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 3(No Describe
Description of urn or container selected: Suitable for shipping: E jtinetery
❑ No
El Deliver to _
ame an ress o e er
'Release to family G-
/ \ ame of Designated amp y m r ecervZremat�e lRemains
❑ 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 m--atertals,
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, and dispose o uch items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO [IDO N� 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 the
remains of the Deceased prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
Description of LnpYnted 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 end
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.I/le 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
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory'sbest effot ts,it iss
'3
fn
K~
3
z.
"Customer's Designation of Intentions" ;
Name of Deceased.: Z—G C� eU20 ctev
•r �,
Cremation: C��: ->:k
cheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family ,
❑ Entombment at ❑ Other (specify): - t
I hereby designate the Disposition of Cremated-Remains and acknowledge receipt of a J
tis form.
n 1 ,,•_
X_ ,tit
(S' n re) tS # j(
_i R•
(Printed Name) w-_ - . (Relationshi Deceased)
!' `YA
Y
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 daystate;,of
cremation may be das osed of by this firm by placeYnenfi,n a col mbarium." ,
r' Printed Name cffuneral Director Signature of eral Director
or UnXertaker . or Un rtaker I
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)
d ,
Name of Person Making Disposition Signature Date
e
t #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
r`