Loading...
Braman, Luella N T07+N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 3� Name 1—U {- �Lh Case # c��' Date of Cremation Time Cremation Started i 3 NL Time Cremation Completed Type of Container lent) r) ` � �b5r-9 '0 b� Remarks : C&O L '-Do1) ice" -1 . E L �� P -o �f�Q TOWN OF QUEENSBURY (\ r ) PINE VIEW CEMETERY&CREMATORIUM 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: (Name) (Sex) 1 (Street) (City) (State (zip) who died on /� day of 2061' A at I (Place) (Address) Name and address of nearest relative or name of person Authorizing cremation: 4,� 6=& �"/,q (Name) (Address) Relationship to the deceased z 1' Name of Funeral Home _ - 2— IMPORTANT: i I represent that to the best of my knowledge, the deceased has o as n 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 remaina and to direct the disposition of the cremated remains, that any personal possessions have either been_rer:&ave1__M or may be destroyed, and agree to protect, defend and save harmless Pine View Cromat�Urn from any and all claims and demands for loss or damages whiat. may--be_made against them by reason of or connected with the cremation of said remains as directed, whether such claiins or demands are or are not wholl groundless, fals r fraudulent. (Witn s) (Addres ) (Signature of Relative or Legal Rep. and Address)) `his date: I I I G� 0311tev.4/98 oa�w AUTHORIZATION FOR CREMATION AND DISPOSITION �' NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMAVI 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 knew no►iving p son who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of ame o eeease7i (hereinafter referred to as the"Deceased"). G 3 Date of Death // r/i' / Time of Death / /'�A.M. , P.M. 01 I/We hereby,request and authorize G� _ �'/!tip^�`""'K- (hereinafter referred to as the "Funeral Home")to take ame o uner ome / possession of and make arrangements for the cremation of the remains of the Deceased at / ame o rematnry (hereinafter referred to as the"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 `X No Describe Description of urn or container selected: Suitable for shipping: - Yes No n A/1_ �_ r�steter}• —i Deliver to ame and Ad0reSS ot"Leme ery Release to family ame o esignated Family Member to ecerve remate emams 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 Unite tates Postal Service. - I The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordanck;witt all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following termspd condiu is 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, veal resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornamen°ts and any other noncombustible items attached to the cremation container prior to cremation.In the event the remains of the Deceased ar received by the Crematory in a casket or other container constructed of metal,fiberglass,or other noncombustible materi:: 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 law` manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a bazar when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we her-x authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains�ofthe D c, prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REN r.,, s���fi, DECEASED DO DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTI��F-nE.a Please initial ofie.�- Listed,below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove fro 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 wilk Ise totally irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to ;-,I the crema chamber during the cremation process and,reposition the remains of the Deceased in order to facilitate a cop.�' , d thord cremation. 4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings,*ewetry,and other per s articles accompanying the remains of the beceased,may be destroyed during the cremation process.We farther authorize W any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber they ma3.be se; from the cremated remains of the Deceased and disposed of by the Crematory. - �udm� 5. I/We herebT authorize the Crematory to separate and remove from the cremation chamber all noncombustible teri4l,- but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. Ak.. Averil 6. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechan:rall to an unidentifiable consistency prior to placement in an urn or other container. — ,ed 7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains 0%t a necea contain ch eevent t'he-is or-desteent�designated is- any ffici nt to accom shipment. modate all of the cremated remains of the Deceased any 8. In the " remains will be placed in a secondary container and returned to the Funeral Home,together with the primary ; mer's Designation of Intentions" sed: t , emation (Scheduled Date) (Location) Manner of Disposition of Cremated.Remains: Jk Burial at -r ,� _-,x. f c-� .-. ElReturn to Family Q Entombment at ❑ Other (specify): # I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of,k 6-py of this form. (Signature) i (Printed Name) (Relationship to Dec i i.') wer` �'• i i (Address) (Telephone Number) "Cremated. Remains which shall not have been claimed. withi*.120 day= cremation may be disposed of by this firm by placement i a Columba Printecl�lVame oun`er`la Director - i' or UnderL ker or'Undertaber TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF D Cremation: r (Actual Date) (Location of Crenlato Disposition of Cremated.Remains: (Manner of Disposition) (I,oj�6on) � s fJ t j'- (Date) i Name of Person Making Disposition Signature Date t. vlf i #9 WHITE:Funeral Home Copy YELLOW.Family Copy PINK-.Crematory Copy CUSINTEN Rev.