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Durkee, Jodi .F rl-O WN OF QUEEVBU-r� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Sr Iyl i OTC, pr Name / �/i �(J�� Case # P Date of Cremation �f—p2� Time Cremation Started Time Cremation Completed Type of Container CAX17 22/?0 Remarks : hn Al 9 c2-'fie '�� r ti IOWtV OF UUEENSI)UUY PINE VIEW CEMETERY CRE111f)TOR I U11 Quaker Road, Queensbury, New York 12004 Phone (510) Crematorium 745-4477 or i r no answer Cemetery 745-4476 AUTt•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 cremate the remains ur : (Name) f�ft��L" bLjd�o�'er<) o u 2 (Street ) (City) (State) (Zip Code) who died/d'�+ 'on Ik day ofp Valy ' ` 2000 at (Place) (Address ) 4 Name and address of nearest living relative or person authorizing cremation : 13op, (Name) (Address) " :.s�,'ps ►a ...E•� -''� 5 w Relationship to the deceased Name of Funeral Home SUU tyaa ELL-dA/{AiJ /�d1dfL I ,IMPORTANT: I represent that to the best of my knowledge, �h,i`de6i�ased has or has no pacemaker in his or her body. (C.ircl a One)'*9"? '. I certify that I have the full power and •aut:horization to arrange for the cremation of the remains and to direct'. the dispos�Vtion of the cremated rremains, that any personal posse"ssions F av`L 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 or fraudulent. /4 AQ4i.k> P-ko F r r It t 7 20 r--A r nc br2, (Witness ) (Address ) (Signature of Relative or Legal Rep. and Address) Signed on this date : 1V0u15fV11 5Z �� � a ow4w AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/9F 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,and know of no living person who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of 17,C�l t NC IZA N,6 (hereinafter referred to as the"Deceased"), ame o eceaseu Date of Death 66 Time of Death_ a',q6 A.M. AEM. I/We hereby request and authorize_ ���t Vl�N I'�I thtA/�ikd �Q L� ) ame oTF unera ome (hereinafter referred/to as the "Funeral Home" to take possession of and make arrangements for the cremation of the remains of the Deceased at Ili at V t 1 1/ (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 19 No Describe Description of urn or container selected: Suitable for shipping: ❑ Yes ❑ No ❑ Deliver to ame an Cemetery Tess eme ry X Release to family J(Z (O l oej (04 Name of DesignatedFamily 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,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 or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may cre a hazard' when placed in the cremation chamber. The-Crematory will not cremate any human remains which contair, ?ny type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we I-.-reby 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 XCONTAIN 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 Ihspasition 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 "ewelry,and other personal articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe 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 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 Crematorv's best efforts,it is y w4 AUTHQRIZATION FOR CREMATION AND DISPOSITION 031 Rev.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,certify,warrant and represent that I/we have the full legal right and authority,and know of no living person who has a superior priority right under state law,to authorize the cremation processing and disposition of the remains of � )a m f"r P Y g >P g Po l D (hereinafter referred to as the"Deceased"). Game ofII�aseT Date of Death / -d Time of Death oZ:QQ A.M. A P.M. I/We hereby request and authorize ame a I a^ 4Hom l 6 (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remnerlll ains of the Deceased at aAi V l,~ W (hereinafter referred to as the"Crematory"). -Name of urematory 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.VWe 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: Suitable for shipping: ❑ Yes El No ❑ Deliver to Cemetery �. Name and Address ot cemetery K Release to family. Q tJ 2)Ql l I J tZ 5( �� ` Name oPDesigna�te family Member to Receive CrematedRemains ❑ 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 D ease-d 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 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 .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,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,*ewelry,and other personal! articles accompanying the remains of the beceased,may be destroyed during the cremation process.We further authorize that ifl 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 cremate 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 i� "Customer's Designation of Intentions"? Name of Deceased: �Ot) o 1 I Ls Cremation: /161,-zi !(,� (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: 0 Burial at 19 Return to Family 11 Entombment at F-1 Other (specify): i hereby designate the Disposition of cremated Remains and acknowledge receipt of a copy of this form. (Siinat—) . , 1 K, 1301— (printed Name) (Relationship to Deceased) x 6qIX. (Telephone Number) "Cremated Remains which shall not have been claimed within 120 days from the date of cremation may be disposed`of by this firm by placement in a columbarium." Printed Name of Funeral Director Signature of Funeral A#"r 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 wHrrE:F6..J Home Copy YELLOW Family Copy PM:Crematory Copy CUSINTIEN Rev.4/96