Holding. Katherine r'-O J+N OF QUEENs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director `j ! f r
Name �� ,���N� 2L2i 146:� Case # /Czl�
Date of CremationTime Cremation Started Z/ / &M f
Time Cremation Completed p9.— 1,3 Z, Fr1y1
Type of Container j6QD 61x 3 /?,O,C/9��8�
Remarks :
i
TOWN OF UUEEN4HURY
PINE VIEN CEMETERY
A
CnEMAtUnIUM
Uuaker Road+ Uueensbury, New York 12804
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHOR I WT I UN TU umrtATE
The undersigned requests and authorize! Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft /
(Name)
(5eN)
(Street ) (City) (State) (Zip Code)
who died on day
��T/ o f UL
a
Ralk)
t
(place) mddress)
Name and address of nearest liVing relatiV* or name of Ptrtut'
authorizing cremat i vn t �- 1JOR
*G C
(Name) tAddr ss)
Relationship to the deceased
Nave of Funeral Nome
-�u i A)A /44
IMpunTANtt knowled a the deceased has or
I resent that to the best of d (Circle Clne)
as no acemaNer in his
or her body.
I certify that I have the full power and authorizatioh to arrange
ion 0
for the cremation of t)ir remains ersonal to di possessions rect the shave teithe
the cremated remains, that any P and a ree to protect, defer.::
been removed or may be destroyed, g
and save harmless Pine View Crematorium frow any and all claimby
s
st them
and demands for loss ordwithesthe crematioich may n mofesaidinremains as
reason of or connectedor demands are or are not wholly
directed, whether such claims
oundlesso false or f au lent' n u
n
(Witness) (Addres-s)
(Signature of Rel tive or Legal Rep- and. Address)
Signed on this datet
DISPOSITION OF CREMATED REMAINS
I Hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrarngemerits - please specify: D
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 f;olidays or Sundays,
arrangements can be made . for Saturday. P-earrangements 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 t`:ie 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
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 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
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 , }candling 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 additional $50 . 00 .
r
"Customer's Designation of Intentions"
Name of DeceaW .90 ,
d ► 7Xrkj�ff l"1/ 1\j i - A
R;
Cremation• 0 at-72%,
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains;
❑ Burial at y Return to Family
❑ Entombment at ❑ Other (specify):
I Hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy,of
this form.
(Signa re)
.;
(P' tell Name) (Relationship to Deceased) '
(Address) €=a,. e,DA
, r
—r r., d t
(Telephone Number)
"Cremated Remains which shall not have been Claimed. within 120 days from the date of
cremation may be disposed of by thifirm by pl ement Acolarium."/ ,2�0
Printed Name of Funeral Director Signature of Funeral Dir 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
N Rev.4/96
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTE
_ _ _ t.--- .._ .......---? --- - c y v VL "UJ %"uluuOLW1C ITAUXIH .
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
mare 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 NOT EX] 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 Impnte[ Device Disosit'on
- DeecnptCoa oI 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. Me 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. n�eot lirm�ed to,hinges,latches,naile orize the r jewelry and precious metals to separate and remove ,and to dispose of suc the cremation c��tea ncombustilole materials, including,lrut
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 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
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 Crematory's best efforts,it is not possible to
all p ores of the g remains of the Deceased,aad that o � p is' ma rem�aurs I/W
Of ere
creme zemaine m the cremation chamber and/or er
authorize the Crematory to dispose of any such residual particles in any lawful manner it deems appropriate.
by
10.Unless I/we give specific written instructions in this Authorization, the cremation, processing and disposition of the remains of the
Deceased will not be performed in accordance with any particular religious or ethnic customs.
11.In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days,the Funeral Home shallVive notice
to me/us by certified mail at the address(es) indicated below. I/We agree that in the event the cremated remains of the
unclaimed, for a p�eriod of 120 days after the date such written notification is mailed, the Funeral Home is authorized anif a to
dispose of the unclaimed cremated remains of the Deceased in any lawful manner it may deem appropriate. ;'
12.I/We agree to indemnify, release and hold the Crema , Funeral Home, their affiliates, , employees.and assigns
"arid all�Oes, damages, liability or causes of action( attorneys'fees and expenses of ation)in connection wi the
Lion of the creme identif the rranains of
tad remains of the Deceased,as au herein,or my/our failure to correctly y th��
disclose the of any implanted mechanical or radioactive devices, or take possession of, or make
��`�` ,j�.y-�f_=1}�(� Pit
c isp sition QI such eremains.
13.Except as set forth in this Authorization,no warranties,expressed or implied,are made by the Funeral Home,Crematory or air;�eir
respective affiliates,agents or employees.
14.I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process. I/We
acknowledge receiving, from the Funeral Home, a copy of the booklet entitled "Cremation Facts" containing additional explanatory
information about the cremation process.
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSITION
I/We warrant that all representations and tements made herein are true and co that I/we have read and understand the provisions
contained' t ve received tl re tior} D4
Xsignature` �'
t p to
Address' i Tel.No.( )
Sit c• S zip
Signature
Print Name p to
Address' T.J.No.( )
ty State Zip
WITNESS:
Date• 6/
ignature Print Name -
Name an Funend Home _
6 WHITE:Funeral Home Copy YELLOW:Family Copy PINK Cemebery/Cle�mtory Copy 031 Rev.10/94
casket
hurry W(:rernanon. In the event the remains of the lleceased are received by the Crematory in a
or other container constructed of metal, fiberglass, or other noncurnbustible 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 Crematcay"40
maize 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 r' 4-
When placed in the cremation chamber. The Crematory will not cremate any human remains which contaof
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a devieby
authorize the Funeral Home, its agents and employees,to remove any such mechanical devices from the remains of tased
prior to cremation, and dispose of such items at its discretion. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DEEASED `
DO = DO NOT 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 retrains of the Deceased
prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
x,
Description o Implan Device Disposition
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Horne.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and
��destroyed�rocess and prolonged exposure
the remains of the Deceased to intense heat and direct�eot�er to authorize the Crematory to facilitate a complete and rho open the cremation chamber
Win$ P reposition P rough 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 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 unidentifiahle 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
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 Crematory's best efforts,it is not possible to
hereby
recover all particles of the cremated remains of the Deceased,and that some particles maytna xtly becomerecommrnglwithOf
other cremated remains remaiui*+g in the cremation chamber and/or other devices u '
authorize the Crematory to dispose of any such residual particles in any lawful manner it deems appropriate.
10.Unless I/we give specific written instructions in this Authorization, the cremation, processing and disposition of the remains of the
Deceased.will not be performed in accordance with any particular religious or ethnic customs. _
11.In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days,the Funeral ' > notice
to me/us by certified mail at the address(ea) indicated below I/We agree that in the event the cremated re. "`'' `` � '
ye ch otifi mailed, th Funeral Ho
un r a G��erimod of 120 da after the date su written n cation is e '••A to
dispose of the un cremated remains of the Deceased lawful deem '' -
in any manner it may appmp :,ya. ;1�}.,':,. • '�'.:;
12. agree to in release and hold the Cremato their aff�lia � lt: r
demnify , Funeral Home, tes, ts, crop -`'
lose, damages, liability or causes of action(inch attorneys'f ees and expenses oftigation)in `"`''' airs
disposition of the cremated remains of the Deceased rized h as au stein,or my/our failure to cornectly' tlre_ ina
tiothne p of�ce of any implanted mechanical or radioactive devices, or asks possession of, orJisposi
13.Except as set forth':,in this Authorization,no warranties, expressed or implied,are made by the Funeral
respective affiliates agents or employees. 0.`'
14.I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process. Me
acknowledge receiving, from the Funeral Home, a copy of the booklet entitled "Cremation Facts" containing additional explanatory
information about the cremation process.
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSITION
I/We warrant that all representations and statements made herein are true and correct, that I/we have read and the p ns
contained in_thie document,and that We have received the ti
s `� .
to
Address: 4
Tel.No.( )
Signature Street City zip �#
Print Name ReWimeMp to
Address Tel.No.( )
r S State zip
WITNESS: Date: .19
Signature Paint Name
Name and AMrm ol Funeral Home
WHITE:1"wne J Horne copy ` YEU.Ow: C
FdII111Y aPYu PINK. etery/CremstoryCopy _�. 031 Rev.10/94
ATTACH
BOOKLET AlnUORIZATION FOR CREMATION AND DISPOSITION
,HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY,BEFORQ. SIGNING
I/We,the undereigned,ce r �t ve tl egad �ty to authorize the cremation,processing and
disposition of the remains of f /�A r+9 (hereinafter retired to as the"Deceased").
Name o�Decea�
�D to of D..e}a}th dQ Time of Death _❑A.M. Xpm.
I/We hereby request and authorize./ IV' (herema referred to as the"Funeral Home")to
Name Fnn H oome
take possession of and maize arrangements for the cremation of the remains of the Deceased at )1;CLtj
(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 custody of the Funeral Hooume. I
understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains o the Deceased are
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 KNo Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cometery
eo
f Release to family ® A) 6i )"
Name of Designated116mily 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,laws,de rulesrocess,ng and re regulations andn of the policies of thee Crematory and Funeral Home, d the following of the Deceased authorized*herein l terms med in and conditions: with all
governing $ n'
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 noncumhustible materials, I/we authorize the remains of the Deceased to he
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 tyhpe of
implant
authorize he Funeral Homemechanical or d tsactive device. In the r.agents and employees,etoremthe
overemains
such{mechanical cal devices from the such
remaiins of device,
the Deceeased
$ P Y , Y
prior to cremation, and dispose of such items at its discretion. LME HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT W 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 Implanted Device Disposition
If no instruction for disposition is given, sua�items maybe 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 y
irrewer.hly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber y
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. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, lrut
not limited to,hinges,latches,nails,jewel 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 um 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 urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated
III > I - r r . 1 .- L- L7_W_ .._,..LL.._.-41 4L- -AAe.4.--