Yates, Ester 70` +N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral D i r e c t o LEA IZ6�
Name Case #
Date of Cremation
Time Cremation Started z/, pjM
Time Cremation Completedgi g,6—rim 1
Type of Container bx a ^(D C
Remarks :
y
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o�ivr�S",°i hr1 r
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ATTACH
BOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOITC THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
We,the undersigned, certify, t IJ legal right and authority to authorize the cremation,processing and
disposition of the remains of = (hereinafter referred to as the"Deceaeedj.
NaAe of Dec n
J)ate of th l �� Tone of Death 0 AA.M. [101.
I/We hereby request and authorize Ij � V (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
(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
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 No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Release to family Name and Address of Cemetery
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, 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 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,-Vwe 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. VWE 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
If no instruction for disposition is given,such items may he disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will he totally and
iaevereihly destroyed by prolonged exposure to intense beat 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 accompanyin the remains of the Deceased, may be destroyed during the cremation process. I/We further
authorize that if any items, o er 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 charfTher all noncombustible materials, including, but
not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of suh;materials.
6. Following cremation, the cremated remains ofth6"Deceased, consisting primarily of bciire 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
ATTACH
BOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOTIC THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
dMe,the undersigned,cert�y, that �full legal right and authority to authorize the cremation processing and
isposition of the remains of l -- (hereinafter referred to as the"Decessedl.
ame o D
Date of Veath � ,{{.��
"� Tine of Death 1�lA.M ❑PM.
I/We � '' (hereina referred to as the"Funeral Home")to
hereby request and authorize
Name Funs Hom ,l
take possession of and snake arrangements for the cremation of the remains of the Deceased at /V f
(hereinnafter referred to as the"Crematory„) Nameof Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the
HhundHome. he possession and custod ofhFuneral
erstand that the se ices and te Cremato �be�ed when the- atremfDem�returned tothe possession and custody the Funeral I/ree rbyaorizl Funeral Home to arrange or the"position of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes No Describe
Description of urn or container selected: Suitable for shipping: JaYes ❑No
❑ Deliver to O.A X �p Cemetery
PL Release to family. I WI!eery
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
' Funeml,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
rocess
g and
osition
f the
governing laws, e rules,nregulationpand Policies of of the Crrematory the
and Funeral Home,and the foled herein lowing g terms and conditions:
e performed in 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 contains 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 be
removed prior to cremation and placed in a combustible cremation contain. 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
un lanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
aut orize 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. IM HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 DO NOT U 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:
i
Description of Implanted Device Disposition
Devices --
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 he placed in the cremation chamber and will be totally and`
irreversibly destroyed by prolonged exposure to intense heat and direct Elaine. 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 accompanyin the remains of the Deceased, may he destroyed during the cremation process. I/We further
authorize that if any items, o er 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 um 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
�y.
s,
b'
r.
"Customer's Designation of Intentions"
` Name of Deceased.: / i A ,�
Cremation: !:& :�
�"
FL-lyt
(Schedu�ed Dat.),.• i
Manner of Disp'os'i"ti of CrematederlTi �= /1 '�'"'�
Burial at 1
Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated. Remains and acknowledge receipt of a copy of
tins form.
x(Sign e)
(Printed Name) 0 (Relationship to Deceased)
IYOAJ
( rese)
tdkakV ,
x �
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
c emation may be dis osed of by the firm by pla ent in col arium.
"
Lx
Pri1j. 4-va Q t)o
nte Name of Funer Director Signature of Funeral Director Date
U f
or ndertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory) k
Disposition of Cremated. Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
TOWN OF UUEEN48UPY PINE VIEW CEMETERY 1,31A
CnEMA MM UM
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or ! F no answer
Cemetery 745-4476
AUTNURIZATiUN TU CREMATE
The undersigned requests and authorize! Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the emairs of!
(Name) (SON)
(Street ) (City) tote) ( Zip Code)
who died on day of �.60.
Io
at (Ploq �JJ ` (Address)
Name and address of nearest liVing relatiVO or name of Ptr%vri
authorizing cremation 1�
(Name) (Address)
Relationship to the deceased / 1
Name of Funeral Nome
IMPUnTANts knowled a the deceased has or
1 to the best of my 9 +
ha no acema in his or her body. (Circle Une)
I certify that I have the full power and authorization to arrange
rect
for the cremaion t-f
tion of the remains ersonald to dipossessionsthe s have(either
the cremated remains, that any p P
been emated or may be destroyed, and agree to protect, defend �►�
and save harmless pine View Crematorium fro* any and all claims
s which may be made against then by
and demands for Ions or damage
the cremation of said remains as
reason of or connected with
direcQ(Witness)
d whether such claims or demands are or are not wholly
g vunal e o Fr 'udulent.
Av POA
(Addres
(Q) ,
(Signature of Relative or Legal Rep. and. Address)
Signed on this date ! � �>��� 1 �0 C:�
r DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
other arrarigemerits - 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
lidaysoa week7 : 00
A M - 3 : 30 P .M. Monday-Friday. arran ements by
arrangements can be made , for Saturday. pre* 9
telephone for acceptance of remains is necessary.
2 . Pine View Crematorium is located
Of dueensburp grounds of the Pine
View Cemetery, Quaker Road, I'o
- 3,_- An authorization for cremation properly signed by the nearest
next of kill 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
Crematorium from any and all claims and
demands
or for onne loss
fwiamages
which may be made against them by reason
cremation.. of th the
said remains and/or disposition of said remains as
h claims or demands are, or are not wholly
directed, whether suc
raudulent . This authorization in addition to
groundless , false or f
-&-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 .
, too 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
11 within three
y of
ion to
mailed i a1R home - handling edU . S .
S. a service , Thereg ill be ma t$20 . 00
the funeral
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 . 00
Children (age 13 months to 12 years ) $.1151 . 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 .