Cook, Glen rrO RN OF QUEEVBU.�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name C'J'F-/V CtsQ Case #
Date of Cremation 02C�
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Time Cremation Started 8� ;O j//y/ f
Time Cremation Completed�4 /MN
Type of Container � /Qr{�
Remarks :
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U(JIJ U1= UUI=LNFUUI(Y
I:P I IJL VIEW l EIIETEI(Y
CREPUITU11 I U111
Quaker goad, Uueensbury, New York 12804
Phone (510) Crematorium 745-447'7 or if no answer
Cemetery 745-4476
f1UTI•I0I1 1 DIT I UN TO CRENFITE
The undersigned requests and authorizes Pine View Crematorium, in
accurdance witty rand subject to its Rules and Regulations to
Cremate tIre re Ilia ills 01`
[Vt r4
(Name ) (Sum)
11�)'J' 1
(Sty et ) (City) (State) (Zlip Code)
who died on 23 day of-' 2000
1811
It (Place) (Address )
Name and address of nearest living relative ur name of person
authorizing cremation :
(Name) (Address)
Relationship to the deceased VVI L _
a n _
Name of Funeral Home_ 12,61, d $ 1)�N/y
IhIPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C-ircle 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 r1emains, 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 cremat:io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
�A 12ao,�b o(r/r rZo r2. �M a as J t l
(Witness ) (Address )
Sign tore of Relative or Legal Rep. and Address)
Signed on this date ;
REGAN 4k DENNY FUNERAL SERVICE
33 Qu"lewd
Qwen*t",NM 2YFi 1U04
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�315)?4`�I114
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"Customer's Customer7s Designation of Intentions"
Name of Deceased.: \,'?u. ,q
"Cremation: /;I izq too 't,14 , V i i.yt 0 Q "f ,y4
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
S Buri at ;,Return to Family
�•,p Ent nt at ElOther (specify):
hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
(Signature)`
(Printed Name) (Relationship to Deceased)
� t
(Address)
(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 columbarium.
/* "
Printed Name of Funeral Director Signature of Fun er ctor Date
or Undertaker or Uncle er
..
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)
s
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
N
o�w AUTHQRIZATION FOR CREMATION AND DISiL;t4
~
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CON
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULL
r
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and k wpriority right under state law,to authorize the cremation,processing and disposition of the remains of
)(hereinafter referred to as the"Deceased"). ame o
Date of Death 621A3 J66 Time of Death $, qO 41-A.M. C P.M.
I c�
I/We hereby request and authorize QA 14 + D47NW (hereinafter referred to as the "Funeral Home")to take
ame ot rtme7iMome ,,
possession of and make arrangements for the cremation of the remains of the Deceased at P11445 V IL:Y4
(hereinafter referred to as the"Crematory"). ame o 'rematory
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 thr
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 2' No Describe
Description of urn or container selected: ,131L41'1 Z Suitable for shipping: K Yes -
❑ Deliver to Cemetery
ame and Address of cemetery
K Release to family —liLs-o-4 C00!,
ame of Designated Member to Receive Cremated Remains
EI 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 I
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 condition__.
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 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 REMA NS-OF"-THE
DECEASED DO ❑ DO NOT K 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 or 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.I/ a further authorize that if
any items,other than the cremated remains of the Deceased,are recovered from the cremation chamber,they maybe-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 Crematory's best efforts,it
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