Remington, Caroline rrnTVN OF QUEE9V
,5B U9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director s/q p(- DR-IY I
NameL /6 /t/Y9 &MI'lVC70-H Case # /
Date of Cremation //- ! - d'coQ
Time Cremation Started /�3® 19,-
Time Cremation Completed Ll ! o�� /� /M
Type of Container �dC9 17 BOX Np�
Remarks :
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TOWN oF UUEENSUURY
PINE VIEW CEMETERY
CREPUITUR I UM
Quaker Road, Queensbury, New York 12804
Phone (510) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AU•fi•iOR 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 I
cremate the remains of
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(Name)
). _(-).
(Street ) (City) (State) ( Zip Cb`de)
who died on day of2000
at (✓)/'G/c Jam✓ '
(Place) (Address )
Name and address of nearest living relative ur per•sun
authorizing cremation :
�S OGl C! 7 t C Y+�i YJ[.C�L.1/� �)Q L�s..J�ct^ L 'yr+M•o E17 Iii LS
(Name) (Address) ii ( . sw
Relationship to the deceased 11��o)')ew ` t s.u� �{ Son
Name of Funeral Home
IMPORTANT: ! `�c
I represent that to the best of my knowledge, the de,c.easa rhas or
has no pacemaker in his or her body. (C•ircle One) "''
I certify that I have the full power and •aut:hor1X4ktT1on to arrange
for the cremation of the remains and to direct. the dis,p4 • , ion of
the cremated rre,mains, that any personal pos5e5sion5 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 or damages which may be made against them by
reason of or connected with the cremat:•ian of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false fraudulent .
(Witness ( tress )
�/ LI/- q- i I
Sign (tune of Relative or Legal Rep. and Address)
Signed on• this date :
031 Rev.4/98
w¢w AUTHORIZATION FOR CREMATION AND DISPOSJTION
NOTICE:THIS 16 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
fi�rr••----�� :n�
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"). Date of Death D Time of Death A.M. ❑ P.M.
I/We hereby request and authorize l� � �»>s 1V >k (hereinafter referred to as the "Funeral Home")to take
ame o ner ome
r�
possession of and make arrangements for the cremation of the remains of the Deceased at F73»C I C_ ame o re ry
(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
arrange for the disposition of the cremated remains of the
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to
Deceased as follows:Is special handling required? ❑Yes o Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
Cemetery
❑ Deliver to ame an rasa o ame ry
❑ Release to family ame o na amp y em r to ecerve remat emams
❑ 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 Registe
red 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 a 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 heI eby
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 NOT�ONTAIN 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
m 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 co ntainer containingthe 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 fillinggs,,��'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process. le further authorize that i
any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separa.egl
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. j
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. �,J
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,any excess cremat6
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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"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
Burial at 4 El Return to Family .
0 Entombment at El Other (specify):
i hereby designate the Disposition of remated Remains and acknowledge receipt of a copy of
this form.
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(Printed Name) (Relationship to Deceased) `7
(Address)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from t6 a.ate o
cremation may he disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signature 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 WHffE-.F...d Ho.Copy YELLOW.Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96