Bach, Francis 70I+N OF QUEEVBUJ Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �( a�.17&:7'N/y
Name Case #
Date of Cremation aq antio
Time Cremation Started
Time Cremation Completed iBQ P! M
Type of Containers
Remarks :
r
TOWN OF QUEENSBURY �
PINE VIEW CEMETERY&CREMATORIUM
t Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
)b 1A C L A Ll:`
(Name) (Sex)
(Street) (City) (State)
(ZIP)
who died on �
,�Lv day of L-)i106/yj43 20v�;
at l )b (Address)
6 LI A(�S
(Place) 3�1/may /�l�
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased_ V11 i:'
Name of Funeral Home
7
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization 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 or damages which may be made against them by reason of or
connected with the cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
,(Signature of Relative or Legal Rep. and Address))
Signed on this date:
` BEAN tic DOWY FUNBjtAL smvi T
Qiwadwy,Now Yat 12804
(318)M1114
"Customer's Designation of Intentions" Y
Name of Deceased: A ), 36Cr!
Cremation: J;t Z20-S&a P/h/c y f of
(Scheduled Date)
(Location)
Manner of Disposition of Cremated. Remains:
❑ Burial at
X Return to Family
'. ❑ Entombment at
❑ Other (specify):
4
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a Copy of
this form.
(Signature)
Z 1,1 XAC-,vim A A CL 9
(Printed Name) (Relationship to Deceased)
12.
(Address)
Qv4;,enlSC �1z y Nt y ,
751- USoy
(Telephone Number
"Cremated, Remains which shall not have been claimed. within 12o 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 ^ ctor -Date
or Undertalw or Undertalzer
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:- .,
(A.I al Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Disposition) p
(Location)
(Date)
Name A*"wX.6.g D;r� Signature Date
yEU-0v-Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
PGY`�C
ti4w AUTHORIZATION FOR CREMATION AND
DISPOSITION 031 Rev.4/9E
N I E:THISIS 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
priority right under state law,to authorize the cremation,processing and disposition of the remains of person who has a superior
(hereinafter referred to as the"Deceased"). t3 e,14—1 �me ar" Le�eyse "—
Date of Death ,'L Time of Death
I/We hereby request and authorize ��: g.— A.M. ;� p M
possession of and make arrangements for the crremmatio f the
her airs of the at (hereinafter referred to as the "Funeral Home")to take
(hereinafter referred to as the"Crematory"). I�IIJL' �/j Inl
1Vame of UremaTor—y--------�
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 y>L No Describe
Description of urn or container selected:
❑ Deliver to Suitable for shipping: Yes n No
ame an Release to famil ress o eme ery Cemetery
ame
y_ L�,(z l���'�J /J�
❑ Scattering at sea by Funeral Home or Funeral Home's agent a� am.r en. r ro ece,ve remat emains
E] Ship via U.S.Registered Mail*
To:Name
❑ Other Address
=e2rall e and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States
.
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 create a hazard
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any t
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 ----- ----- - - - - - - —.g--_-
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 ad
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cremationn`-
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 fillingsZ�'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.s/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 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,toEether with the nrimnry urn nr rnntain—