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Shaw, Johanne #3 TOWN OF UUEENg"y PINE VIEW CEMETERY CREMWUR I UM Qualrer Road, Queensbury, New York 12804 phone (5181 Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHURItATION TU CREMATE The undersigned rquesg ��dau��oigd* p inv View / in accdrdance with � Rlesand Regulations t,o cremate the remains oft (Name) S'cheeoy kt (City) (State) (Zip .ode) (Street ) �_d who died on a y a f�aJ-- at ws.?REt1.1 0 (place) (Address) Name and address of nearest liVing relatiVO or name of per�ori authorizing cremation! cfO . �d7tf E PI E ,► � y��I I _ AE/E.J (Address) j (Name) Relationship to the deceased k Name of Funeral Name IMPURTANts re resent that to the best of my knowledge, the decirasedC**,,Pr acwmaker in `!T+-9-� her body. (Circle One) the full power and authorization to arrange I certify that I )rave for the cremation of the)lremanyspersonal and to dtpass@%%tonss have teither the cremated remains, personal and a ree to protect, defend been removed or may be destroyed, g and save harmless Pine View Crematorium from any and all claims ay be made against them by and demands for loss or damahestheicrrematiarr of said remains as reaso n of or connected With or are not wholly directed, whether such claims or demands are grvundiesso alse or fraudulent. -_ Z� � ( ness) (Address • I (Signature of Relative or Legal Rap• and. Address) Signe d an tilts date t • I D1:SPOSITION OF CREMATED REMAINS I Hereby direct Pine View Crematorium to dispose 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 holidays or Sundays, arrangements caii 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 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 crema'-ion . of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are not wholly groundless , false cr 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 conta_Lner. 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 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 ) $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 addwtional $50 . 00 . • Sullivan - Minahan & Potter 407 Bay Rd Queensbury NY 12804 "Customer's Designation of Intentions" Name of Deceased: j4,4A"Na , A g&O',, Cremation: (Scheduled Date) (Location) Manner of Disposition of Cremated. Remains: Burial at Se i h,ic1r C ,FnM , ❑ Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a ray of this form. (Signature) d/ `♦e» (Printed Name) (Relationship to Deceased),.,,: (Address) .• f { / V V / [� (Telephone Numher) j "Cremated Remains which shall not have been claimed. within 12o days from the date of cremation may he disposed of by this firm by place ent in a columharium." 'V 'G(P •f' ._.A to /(r r. fuT�.i C ..+' s.s Printed Name of Funeral Director Sign a'of Funeral Director Date or Undertaker or Undertaker �i aa" TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINN --�:_ 11I Cremation: T .1 (Actual Date) (Location of Crematory) Disposition of Cremated.Remains: (Manner of Disposition) i (Location) I (Date) i I Name of Person Malting Disposition Signature Date i #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.V96 ;I ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE 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, cer t. 1 warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and disposition of the remains kh.- W L Sl"A84) (hereinafter referred to as the"Deceased"). Name of Deceased Date of Death�/ D06 Time of Death Y•W f WAM. ❑PM. I/We hereby request and authorizeSw//;V*,Q + rniNj*`iAN f 70 4-a— (hereinafter referred to as the"Funeral Home")to Name of Funeral Home take possession of and make arrangements for the cremation of the remains of the Deceased at.&?E44EW �iPEiY/A�11P�`Nn (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we ions he Cremat be he Deceased are to theunderstand �sd that custodys and of the Fluneral Home.e. I/We hereb uthooriz�leFu hers Home to arrangeen the mains for the disposition of the returned r muted P Y Y remains of the Deceased as follows: Is special handling required? El Yes XNo Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No Deliver to Sevix S;d&,:� &I1 SO 154611 Fdl k /V,/. /.76 03 Cemetery Name and Address of Cemetery ❑ Release to family Name of Designated Family Member 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 rocessing and isposition of the remains of authorized herein shall e performed in accodance governing laws, e rules regulations and policies of the Crematoryyand Funedral Home,and the followinbg terms and conditions: with all 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 noncumbustible 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 of the Deceased =DOC:��Iil ation, and dispose of such items at its discretion. UWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED O NOT ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. itial 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: f"CLC_e—M GL K e!— 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 Deceased, 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 he separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. �yl but d toreh uhinges,thorize the latches, nailer jewelr to y and preciousarate mremovetale�and to dispose of sum the cremation ch er materials, including, but not6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to j 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 designed 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 .111 1 1 . 1 1 1 . .1 T, ITT . - .1 ..1 .1 ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE ddOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY$EaFORL$SIGNING I/We,the undersigned, certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and disposition of the remains otA ANi✓,E SA a (hereinafter referred to as the"Deceased"). Name of Dec �' " Date of Death 111Z 11 C" Tune of Death q- 00 AA.M. ❑P.M. I/We hereby request and authorize.s'K//i y'a o-,4;n/R/f►,a o 47ttf ,Q. (hereinafter referred to as the"Funeral Home")to Name of Funeral Home n take possession of and make arrangements for the cremation of the remains of the Deceased atRA10 &A0 L iPE/11!?�of?i lsm (hereinafter referred to as the "Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we d when the to the possession sssind oln and custodt the ys and of the Funeral Homions of te e Crematory I/W hereby shuthoorizall be �leFune al Home to arrange remains for the disposition d are of the crmt cremated P Y Y remains of the Deceased as follows: Is special handling required? ❑Yes C9 No Describe Description of urn or container selected: /- Suitable for shipping: El Yes El No ®. Deliver to�����f"EM Sd G/6NP &11-s /✓.X• Cemetery Name and Address of Cemetery ❑ Release to family Name of Designated Family Member 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, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,de 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 noncumbustible 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 aui ' e Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased or to cry tion, and dippose of such items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO O NOT ? JCONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. initial one. List ow 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 he totally and j 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 Deceased, may be destroyed during the cremation process. I/We further j authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may he separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. I/We hereb 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 hone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an um or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated j TOq+N OF QUEEVBUS,y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director,:2.1 Name 44 ,S 4) Case # Date of Cremation // — Time Cremation Started 2�/ ' Pit:9-d l m t Time Cremation Completed $ti Type of Container a�ly Remarks : !Mr f 4 !M ! N7 r rM I g�3� M